摘要：The author traces the development of the concept of health promotion from 1980s policies of the World Health Organization. Two approaches that signify the modernization of public health are outlined in detail: the European Health for All targets and the settings approach. Both aim to reorient health policy priorities from a risk factor approach to strategies that address the determinants of health and empower people to participate in improving the health of their communities. These approaches combine classic public health dictums with “new” strategies, some setting explicit goals to integrate public health with general welfare policy. Health for All, health promotion, and population health have contributed to this reorientation in thinking and strategy, but the focus of health policy remains expenditure rather than investment. IN 1986, AT AN INTERNATIONAL conference held in Ottawa, Ontario, Canada, under the leadership of the World Health Organization (WHO) (and with a strong personal commitment from then Director General Halfdan Mahler), a broad new understanding of health promotion was adopted. The Ottawa Charter for Health Promotion has since exerted significant influence—both directly and indirectly—on the public health debate, on health policy formulation, and on health promotion practices in many countries. 1, 2 The work on this document was spearheaded by the WHO European Regional Office and was developed over a period of 5 years of intensive research and debate. It was based on the “Health for All” philosophy, 3 the Alma Ata Declaration, 4 and the Lalonde health field concept. 5 The Ottawa charter initiated a redefinition and repositioning of institutions, epistemic communities, and actors at the “health” end of the disease–health continuum, a perspective that had been labeled the “salutogenic approach” by Aaron Antonovsky. 6 In overcoming an individualistic understanding of lifestyles and in highlighting social environments and policy, the orientation of health promotion began to shift from focusing on the modification of individual risk factors or risk behaviors to addressing the “context and meaning” of health actions and the determinants that keep people healthy. The Canadian Lalonde report is often cited as having been the starting point of this new development. Recently the director of the Pan American Health Organization, Sir George Alleyne, reflected on this issue, stating that “it is perhaps not accidental that the impetus for the focus on health promotion for the many should have risen in Canada which is often credited with maintaining a more egalitarian approach in all health matters.” 7 In its Health for All strategy, WHO positioned health at the center of development policy and defined the goal of health policy as “providing all people with the opportunity to lead a socially and economically productive life.” 3 It proposed a revolutionary shift in perspective from input to outcomes: governments were to be held accountable for the health of their populations, not just for the health services they provided. Lester Breslow, the father of the Alameda County study and one of the world’s leading epidemiologists, had argued in 1985 that “the stage is set for a new public health revolution.” 8 The Ottawa charter echoed this challenge as well as the link to public health history in its subtitle, “The Move Towards a New Public Health.” Fourteen years later, in a commentary published in the Journal of the American Medical Association , Breslow deemed the Ottawa charter the document that has best captured the essence of the third public health revolution by conceptualizing health as a “resource for living” and shifting the focus from disease prevention to “capacity building for health.” 9 In many parts of the world, influenced in particular by WHO and the Pan American Health Organization, health promotion has come to be understood not only as an approach that moves “beyond health care” but also as a commitment to social reform and equity. The Pan American Health Organization included the categories of the Ottawa charter in its 2001 annual report, and the director’s message stated: “For an organization devoted to health, such as ours, the main strategies of health promotion can find application in almost all aspects of our work.” 7 The Ottawa charter frames health as a resource that is created in the context of everyday life and defines health promotion as “the process of enabling people to increase control over, and to improve their health.” It defines health as “a resource for everyday life, not the objective of living.” It adds that “health is a positive concept emphasizing social and personal resources, as well as physical capabilities.” Following in the footsteps of the best traditions of public health and social medicine and making full use of the research on the impact of social factors on health, it links the production of health explicitly to “prerequisites for health” such as peace, income, and housing and—most important—defines health promotion as a process of empowerment and capacity building. The charter outlines 5 key action areas that reinforce one another with the goal of improving the health of populations: (1) the development of healthy public policies (policies supportive of health in sectors other than health), (2) the need to ensure environments supportive of health, (3) the importance of personal skills, (4) community action, and (5) the challenge of reorienting health services. A new mind-set and professional ethos are proposed for health professionals; their new role is to “enable, advocate, and mediate.” This approach to health promotion found its dissemination and application through a number of channels. Here I focus on 2 of these channels: the European health targets and the settings approach.
