BENGT LINDSTRÖM, PhD, DrPH, MD

2012-11-19
IN SEARCH OF A FUTURE
FOR HEALTH PROMOTION
Université Laval, Québec
21.11.2012
BENGT LINDSTRÖM, PhD, DrPH, MD
Professor of Salutogenesis, NTNU, 2011, NO
bengt.lindstrom@svt.ntnu.no www.rchpr.no
Chair of the IUHPE Global Working Group on Salutogenesis
www.salutogenesis.fi www.salutogenesis.hv.se
ALSO
Associate Professor Political Science, Åbo Akademi Vasa, FI
Associate Professor Public Health, Tampere University FI
Associate Professor Child Public Health, NHV, SE
RECENT PREVIOUS POSTS
Professor of Health Promotion and Public Health, Nordic School of Public Health 2006
Professor of Health Promotion, HiBu NO 2008
Research Director Health Promotion Research, Folkhälsan Research Center, FI
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2012-11-19
THE IUHPE GWG SAL
Health Promotion and
Resources, NO
Hemil Senter,
Högskolan Väst, SE
NO
U of Newcastle
EMERY,
USA
NICE
U of Girona
ES
Steno HP Research, DK
Society and Health,
Wageningen, NL
U of Zurich; Vienna
WHO EURO, Venice, It
Ben Gurion Univ, IL
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MY OWN ENTRY POINT
THE EXCAVATION OF HEALTH
THROUGH QUALITY OF LIFE
From
MEDICINE
to
PUBLIC HEALTH
&
HEALTH PROMOTION
then
SALUTOGENESIS
and finally
LIFE PROMOTION
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PROVADIA, BULGARIA (4700-4200 BC EUROPES OLDEST CITY)
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2012-11-19
WHAT IS HEALTH?
THE WHO DEFINITION 1948 or Something
Different?
Today a strong rethoric emphasis on the
”wellbeing” part of the concept
but
practice still focused on the absence of disease,
and risk reduction
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Health, Disease, Quality of Life
H- --------------------------------------------- H+
D- --------------------------------------------- D+
QoL- ------------------------------------------- Qol+
____________________________________
VAD GER SALUTOGENES OCH HF TILL DETTA
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2012-11-19
My Historic Nisch
Towards healthy public policy:
experiences in Finland 1972–1987*
“Any public policy can only be
understood in a historical and societal
context. Therefore, a brief introduction
to the political, economic, social and
cultural background is necessary. “
Tapani Melkas, Kimmo Leppo, HPI 1988, 3:2, 195-203.
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FINLAND, ”WHO´s GOOD BOY”. IN 1972
PUSHED FOR A QUICK POLITICAL HEALTH CARE
REFORM TURNING THE HEALTH CARE SYSTEM
UPSIDE DOWN OVER NIGHT.
”THE PRIMAL CRY”
(PS HOPE OBAMA GETS THE CHANCE)
(A social democratic government - polls against - supported by the
status of the Finnish Regional WHO Director in Copenhagen (Leo Kaprio)
Further inspired by the trends of the sixties and Maos Barefoot Doctors
succeeded!! )
.................and we started the
North Karelia Project
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2012-11-19
WE HAD IT ”BAG IN A BOX” AND THE MOST
ADVANCED PRIMARY HEALTH CARE REFORM EVER
WAS ACHIEVED
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AND THE NORTH CARELIA PROJECT........
The North Karelia Project
Nothi ng
FINLAND AND SCOTLAND
FINNISH CVD MORTALITY
1970
– 1990
SCOTTISH CVD MORTALITY
1970 - 1990
MASSIVE INTERVENTIONS
FROM 1972 ONWARDS
NO INTERVENTIONS AT
ALL
THE NORTH KARELIA
PROJECT
THE GLOBAL FLAGSHIP
FOR CVD PREVENTION and
COMMUNITY INTERVENTIONS
NOTHING
except for
HAGGIS, WHISKY AND A SMOKE, and
SOME EXELLENT DEPRIVATION
STRATEGIES
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THE DECLINATION PATTERNS EXACTLY
THE SAME
from 1950 to 1960 an increase and after that a decline almost in parallel
In Finland
WHY?
and Scotland
WHY?
Are our explanations and
interventions too simple?
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2012-11-19
HOW DOES ONE EXPLAIN THE CVD
EPIDEMIC IN FINLAND ??
• Genetics
• Lifestyle (alcohol, tobcco,
Food exercise....)
• The social gradient Not
good to be poor at all
• Mental problems
• A great stressor behind the
border – Soviet Union (FI)
•
•
•
•
What about epi-genetics?
What about stress theories?
What about history?
Was North Carelia only
timed right by chance??
• However The Research and
Intervention gave us a lot
of experience to build on
further
• BUT at the same time a
belief in a paradigm that
has been impossible to
break over 40 years!!
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Cardiovascular disease deaths
The temporal relationship between risk factor change and the
corresponding change in cardiovascular disease mortality has been
perceived in terms of decades.
However, evidence from clinical trials, natural experiments and
policy interventions consistently suggests that changes in diet and
lifestyle across entire populations can be quickly followed by
dramatic declines in mortality. WW I and WW II ??
Although politically difficult, population-wide policy interventions
for cardiovascular disease prevention could result in substantial and
fast reductions in mortality and cost savings
Can dietary changes rapidly decrease cardiovascular mortality rates?Simon Capewell* and Martin O'Flaherty
bEur Heart J (2011) 32 (10): 1187-1189.
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2012-11-19
You can fool Some of
the people All of the
time,
All of the people
Some of the time,
But you can never fool
All of the people
All of the time.
Abraham Lincoln
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2012-11-19
AND...
SEVEN YEARS LATER
THE EMPIRE STRIKES BACK
1979
AND
THE MONEY POORS BACK INTO THE
SPECIALISTS AND HOSPITAL SYSTEM
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
TO GET IT BACK TODAY IS RATHER A
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TAKE IT AS AN EXAMPLE OF A POLICY FAILURE
R
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2012-11-19
The Classic River of Health
Mac Kinley 1974
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The journey from Ottawa to Health 2020
Halfdan Mahler, WHO Director
WHO in Ottawa 1986
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THE ALMA ATA DECLARATION 1978
FOR PRIMARY HEALTH CARE
all health workers and the
world community to support
national and international
commitment to primary
health care and to channel
increased technical and
financial support to it,
particularly in developing
countries
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Probably the most important Health
Policy change so far:
The WHO HFA Strategy 2000
of 1981/84
- Adding Years to Life (AYL)
- Adding Life to Years (ALY)
- A Sustainable Development
- Equity in Health”
- Intersectoral Action
......and 38 Targets.
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HEALTH AS A PROCESS
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1986 The Implementation Strategy the
Ottawa Charter for Health Promotion
”Health Promotion is the Process Enabling
People to Gain Control over their Health
Determinants Thereby Improving their Health
and allowing them to lead an Active and
Productive Life”
The ”Genetic Code of Health Promotion”.
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THE FIVE ACTION AREAS
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Do not forget North Karelia
The ”Genetic Code” of Health Promotion
THE EMBEDDED PRINCIPLES AND VALUES
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Lindström B, Eriksson M. The Hitchhiker’s Guide to Salutogenesis. Salutogenic pathways to health
promotion. Helsinki 2010.
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DEATH AND DISEASE,
Lindström, Eriksson 2011
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The River Of LIFE
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The Commission on Social Determinants of Health, 2005-2008
WHO called to return to the
Declaration of Alma-Ata
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SIR MICHAEL MARMOT AT THE WHO
7th WORLD HEALTH PROMOTION
CONFERENCE, NAIROBI 2009
”IT IS NOT
A QUESTION HEALTH PROMOTION NOT HAVING
THE RIGHT APPROACH TO IMPROVE THE HEALTH OF THE
POPULATION REDUCING INEQUITY IN HEALTH
IT IS ALL EMBEDDED IN ITS PRINCIPLES
BUT RATHER
A QUESTION OF THE PROFESSIONALS IN HEALTH PROMOTION
NOT DOING WHAT THEY ARE SUPPOSED TO DO !!!”
NEXT: (WHO 8th HEALTH PROMOTION CONFERENCE HELSINKI 2013 )
HiAP
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2012-11-19
WHO CONSULTANCY on HiAP
0ctober 9 - 19.2012
in preparation of the WHO 8th
Health Promotion Conference
Helsinki 2013
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“HiAP is an integrated part of society´s welfare
policies, an organized effort to create structures
and sustainable processes delivering health and
wellbeing contributing to wealth and in the long
run prosperity for all. “
It is based on equity and human rights securing a
fair distribution and use of our global resources.
Bengt Lindström, Professor of Salutogenesis
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STRUCTURE
HOW FAR CAN WE EXPECT TO GO?
SWEDEN TRAFFIC ZERO VISION
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TRAFFIC SAFETY AS HEALTH PROTECTION
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Mats-åke Belin Trafikverket,SE
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2012-11-19
Probability of Pedestrian Fatality by Impact Speed
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Mats-åke Belin Trafikverket, SE
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Mats-åke Belin Trafikverket, SE
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2012-11-19
NEXT
HEALTH
PROCESS AND
DIRECTION
ARON ANTONOVSKY
HEALTH +
SALUTOGENESIS: THE SOC THEORY
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Conceptually, salutogenesis is defined as
...
”the process of movement toward
the health end of a health ease/ disease continuum.”
Antonovsky A. The salutogenic approach to aging. Lecture held in Berkeley, January 21, 1993.
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© Monica Eriksson 2010
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Salutogenesis, the exploration of the origin of
health, emphasising human strengths and not just
weaknesses, human capacities and not just limits,
well-being and not just illness, and so on…
It is a system approach to health that also can be
applied on organisations like schools, hospitals,
communities, cities, business organisations....
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Sense of Coherence
... is a global life orientation – a
way of viewing life as coherent,
structured, manageable and
meaningful.
... is a way of
thinking, being
and taking action
as a human being.
... is a confidence to be able to
identify internal and external
resources, use and reuse them
in a health promoting manner.
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© Monica Eriksson 2010
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Generalized Resistance Resources
(Antonovsky 1979, 1987)
Material (money, housing…)
Biological/mental (self-esteem,
intelligence …)
Emotional (contact with your feelings,
social relations …)
Physical (heredity, healthy orientation
…)
Existential (beliefs, religion, meaning
of life …)
Meaningful activities
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© Monica Eriksson 2010
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The Key ...
it is not only about the resources at
disposal but the ability and
flexibility to use them in a health
promoting manner.
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© Monica Eriksson 2010
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BUILDING BLOCKS FOR HEALTH PRMOTION PROCESSES
(or SALUTOGENIC PROCESSES
UNDERSTAND
SOC
MEANINGFULNESS
MANAGEABILITY
GRRs
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The development of a strong SOC
Psychoemotional rather than socioeconomical factors
THE KEY GRRs:
1. Being in contact with ones
inner feelings
(Antonovsky 1979, 1987)
2. GOOD Intimate relationships
(Antonovsky 1979, 1987)
CHILDHOOD CONDITIONS INCLUDE
A load balance and consistency
(Sagy & Antonovsky 1996)
Participation in shaping the
outcomes (empowerment)
(Sagy & Antonovsky 1996)
Appropriate childhood conditions
3. Enjoying good Social support
(Antonovsky 1979, 1987; Shawn et al. 2007)
4. Having meaningful everyday
activities
(Antonovsky 1979, 1987)
5. Existential coordinates in
place (Antonovsky 1979, 1987)
(Antonovsky 1979, 1987)
Absence of family conflict good
neighbourhood cohesion (Shawn et al.
2007)
Introspection and reflection about
job engagement (Forbech Vinje &
Mittelmark 2007)
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© Monica Eriksson 2010
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Generally - A strong SOC ...
… protects against anxiety, depression, burnout and hopelessness
… is strongly and positively related to health resources such as
optimism, hardiness, control, and coping
... predicts good health and QoL from childhood to adulthood
… the stronger the SOC the fewer the symptoms of mental
illnesses
Eriksson M, Unravelling the Mystery of Salutogenesis, 2007; Nielsen AM, Hansson K Stress and Health
2007;23(5):331-341; Sagy S, Braun-Lewensohn O. Global Health Promotion 2009;16(4):5-15;
Simonsson B, Nilsson KW, Leppert J, Diwan VK. BioPsychoSocial Medicine 2008;2(4):doi:10.1186/17510759-2-4; Buddeberg-Fischer B, Klaghofer R, Schnyder U. Soz Praventivmed 2001;46(6):404-410...
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© Monica Eriksson 2010
Mental
health
The stronger the SOC the better the QoL
on children, adults and in families.
Findings from both quantitative and
qualitative studies support the SOC to be
a factor enhancing good QoL.
Results from longitudinal studies
confirmed the findings from the crosssectional ones.
Most of the studies are using specific
questionnaires for measuring HRQL on
varying samples (patients).
Studies measuring QoL on general
populations are scarce.
Eriksson M, Lindström B. J Epidemiol.
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Community Health 2007;61:938-944
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The Evidence Base
Research synthesis based on
about 500 papers and doctoral
thesis (1992-2003)
Ongoing analysis of
additional 400 papers 2004 2009
Personal communication
with authors
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© Monica Eriksson 2009
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2012-11-19
HOW DO YOU CREATE
COHERENT HEALTH
PROMOTING SETTINGS??
DEVELOPING YOUR SENSE FOR COHERENCE!
USING:
HUMAN RIGHTS, (ACTIVE PRTICIPATING SUBJECT)
THE PRINCIPLES OF THE OTTAWA CHARTER (GENETIC CODE),
QOL (CONTEXTUAL MODELS: LINDSTRÖM AND CANADIAN BEING
BELONGING BECOMING...)
WELFARE MODELS (SWEDENER; ALLARD)
ECOLOGICAL MODELS (BRONFENBRENNER, HANCOCK..)
SALUTOGENESIS (SOC AND ITS DIMENSIONS. HERE TRY TO DISCUSS
SOC ON BASIS OF THE EVIDENCE OF PSYCHO-EMOTIONAL AND
CONTEXTUAL UNDERSTANDING TO CREATE COHERENCE )
FOCUS ON WHAT ARE THE SOC-DETERMINANTS
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THE SALUTOGENIC SOCIETY
“ Life promotion is the process of enabling
individuals, groups or societies increase their
control over, improving their physical, mental,
social and spiritual health. This could be reached
by creating environments and societies
characterized of clear structures and
empowering environments where people see
themselves as active participating subjects who
are able to identify their internal and external
resources, use and reuse them to realize
aspirations, to satisfy needs, to perceive
meaningfulness and to change or cope with the
environment in a health promoting manner.”
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THE SALUTOGENIC UMBRELLA
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HP = (SAL+QoL) HR
OC
HHG Salutogenesis 2010 Modified Bengt Lindstrom
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Healthy learning: Salutogenesis as a learning process in the context
of health promotion.
THE SALUTOGENESIS
THE OTTAWA C HARTER
PROLOGUE
The Holocaust and its Survivors
UN Declaration of Human Rights
WHO Definition of Health
TIME REFERENCE
Antonovsky 1978, 1987
1986
STATUS
Theory, evidence
Principles, Policy, ideology
FUNDAMENT
Human Rights, i.e. active participating subjects
Human Rights, i.e. active participating
subjects
FOCUS
Life Orientation
Health Promotion
HEALTH
As a life long learning process
A Process
KEY CONCEPTS
SOC, GRR
No? Health promotion?
RESOURCES
Generalized Resistance Resources
Health determinants
KEY MECHANISMS
Ability to use GRRs to develop a SOC
Enable control over health
determinants (Empowerment)
ELEMENTS
Comprehensibility, Manageability,
Meaningfulness
APPROACH
Contextual system
Settings
OUTCOME
Mental health, Quality of Life, Perceived health
A better health, active productive life
PROFESSIONAL ROLE
Serve as a GRR
Facilitator enable people
MISCONCEPTION
Only measure SOC
Only risk approach-health behaviour
© Bengt Lindström, Monica Eriksson 2008
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www.salutogenesis.hv.se
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REFERENCES:
Lindstrom B Eriksson M. The Hitchhiker´s Guide to Salutogenesis
Folkhälsan Research Report 2, 2010
Lindström B et Eriksson M, La salutogenèse, petit guide pour promouvoir la santé,
Québec, PUL, 2012, 109 p. (adaptation française: Mathieu Roy et Michel O'Neill).
Eriksson M. Unravelling the mystery of Salutgogenesis
Folkhälsan Research Report 1, 2007
The Ottawa Charter for Health Promotion, WHO 1986
The Health for All Strategy , WHO 1984
The Public Health Act for Primary Care, Finland 1972
Lindstrom B Eriksson M The Salutogenic Appraoch to the making of HiAP illustrated
by a case study. Global Health Promotion 2009; 16 (1) ; pp 17-28
Antonovsky A The Salutogenic Model as a theory Guide to Health Promotion Health
Promotion International 1996 1:1 pp 11-18.
Eriksson M Lindstrom B. A Salutogenic Interpretation of the Ottawa Charter HPI
Advance Access March 2008.
Lindsrom B. A journey to the Center of Health - some views and reflexions plotting a
salutogenic roadmap towards Next Health and a salutogenic society. Research
Report of RCPHR 2012 available at www.rchpr.org see international seminar 2012
Videos: YouTube: Life is Beautiful scene 13. From Ottawa to Health 2020 (WHO
Euro)
Clips from:
Jakten på Nazismen, SVT.
Halfdan Mahler on Spiritual Health (NHV 1987)
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