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Chapter 8- Textbook
Definitions of Health and Health Promotion
Health is a difficult concept to define.
According to the Oxford etymological dictionary (Hoad, 1996):
Health is described as a state of sound body, mind, and spirit; a state of wholeness.
The traditional Euro-Canadian understanding of health and health care is based on the biomedical model:
Health is often understood as the absence of disease and illness, rather than a state of wholeness.
Biomedical perspective: To achieve health, one must attend to physical pathology (Kaplan, 2000).
Dynamic Nature of Health:
Health should be seen as a dynamic process with evolving assumptions and understandings over time.
Nursing has defined health as an evolving holistic human experience that encompasses multiple professional perspectives.
The medical definition is viewed as just one aspect of health (Payne, 1983).
Importance of Health Promotion:
Health promotion is considered the foundation of nursing practice (Canadian Nurses Association [CNA], 2009).
Nurses collaborate with multiple professions in interprofessional and multisectoral teams to:
Promote
Support
Maintain
Restore health in individuals, families, communities, and populations.
In 1946, the World Health Organization (WHO) broadened the definition of health:
Health is now defined as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (WHO, 1948).
This shift moved the focus from disease control to a more comprehensive understanding of what it means to be healthy.
Various health-related professions have adapted the WHO definition to create tailored definitions to inform their own practices:
Anthropology: Defines health as bound within the political, economic, and religious domains of society (Kleinman & Petryna, 2001).
Sociology: Emphasizes person-centred care to include human capabilities and meaningful experiences (Frank, 2013).
Social Work: Considers health in terms of integrating services to improve function, longevity, and quality of care (Fisher & Elnitsky, 2012).
Community health nurses (CHNs) define health as:
“A resource for everyday life that is influenced by circumstances, beliefs, and determinants of health” (CHNAC, 2008, p. 10).
Based on the principles of social justice, CHNs strive to protect health for everyone, regardless of circumstances.
Holistic View of Health:
Individual and family views on health may reflect immediate needs (e.g., social support during illness, basic needs like food and shelter).
Within the lens of social justice, health can mean living in a fair society with equitable access to resources, education, and opportunities.
Nature of Health Promotion:
Health promotion has a complex history in Euro-Canada and globally; full implementation is ongoing and challenging.
Health promotion is often narrowly equated with health education, which is just one part of a larger strategy:
Health education helps increase knowledge and may assist in behavioral changes.
WHO’s definition of health promotion (2009a): Health promotion is the process of enabling people to control and improve their health, viewing health as a resource, not an end goal.
Framework of Health Promotion:
Health promotion actions must go beyond strengthening skills; they need to change social, environmental, and economic conditions impacting health (WHO, 1998).
Essential for nurses to understand community needs and facilitate changes based on those needs, similar to a collaborative approach.
Factors Contributing to Health Promotion:
Involves various activities and strategies, encouraging community participation to improve health.
Can be seen as a multi-faceted process combining educational, political, regulatory, and organizational activities that support healthy environments (McKenzie, Neiger, & Thackeray, 2013).
Emphasis on partnerships and community involvement as critical for achieving long-term health impacts (Franco-Paredes et al., 2010).
Nursing Activism:
Nursing involves advocating for broader changes to promote health, recognizing the importance of addressing the social determinants of health.
Examples of Canadian nursing activism include efforts like those of Cathy Crowe and Cheryl Forchuk addressing issues such as homelessness and mental health integration.
Indigenous Health and Health Promotion
Euro-Canadian understanding of health framed from an individualistic and biomedical lens.
Indigenous understanding of health arises from a broader, more holistic, community-focused lens:
Wellness achieved through a balance of the body, mind, emotion, and spirit.
Holistic health requires family and community collaboration:
Each part enhances, supports, and affects the other.
Individual wellness results from how each factor is addressed (Cameron et al., 2014).
Good health is connected to:
A sense of community
Personal identity
Practice of cultural and spiritual traditions (Cameron et al., 2014).
The land plays a crucial role in maintaining:
Cultural identities
Social relationships
Health and well-being (Richmond, 2015).
Living in harmony with nature is integral to the health of Indigenous peoples worldwide (Bourque Bearskin et al., 2016; Cameron et al., 2014).
The WHO definition of health promotion is critical for Indigenous populations in Canada in the recovery from cultural genocide, due at least in part to the residential school system (see Chapter 22).
Colonization has led to the loss of traditional health and wellness systems:
Indigenous peoples feel disconnected from external definitions of what it means to be healthy (Dion Stout, 2015).
Health Promotion involves:
Regaining control and power in reclaiming culture is essential.
Ethical Indigenous health promotion requires health practitioners to relinquish control over the health promotion process.
This poses challenges within a Euro-Canadian health care system.
Empowerment must be a key component, focusing on engagement rather than merely effects on behavior (McPhail-Bell et al., 2015).
Shift in research about Indigenous populations includes:
Utilizing Indigenous methodologies and ways of knowing.
Control over the research process must be in the hands of Indigenous peoples.
The Truth and Reconciliation Commission of Canada’s Calls to Action (2012) and the United Nations Declaration of the Rights of Indigenous Peoples (2008) serve as starting points for raising awareness and encouraging action for health-promoting change that involves all Canadians in the healing process.
Upstream and Downstream Approaches to Promoting Health
McKinlay (1994) presents a story illustrating upstream and downstream health promotion approaches.
Setting: A town in a valley relying on a river for drinking water.
Despite its picturesque appearance, annual health issues include diarrhea, vomiting, and dehydration.
Most affected: Young children, vulnerable individuals, and older adults.
Town health department interventions:
Implemented strategies to promote health:
Boiled water advisories communicated through media outlets.
A few wells offering clean drinking water but with low flow rates, accessible only to affluent families.
Funds allocated for antibacterial pills and antibiotics for sick individuals.
Outcome:
Despite strategies, morbidity and mortality rates due to gastrointestinal infections are 10 times the national average.
Unrecognized factor: An upstream factory discharging unfiltered sewage into the river.
Factory owner received prior approval to dump waste due to being organic and biodegradable.
Increased size and number of factory operations lead to worsened conditions.
Community assessment:
Public health nurses conducted water tests revealing high bacterial counts.
Municipal reports indicate 15 years since sewage policy reviews.
Observations of waste discharge from factory sewage pipes contribute to contamination.
Recommendations:
Encourage the town health department to address upstream issues to ensure clean water for residents.
Financial constraints:
Town council prioritizing antibacterial treatments and boiled water advisories without funds to resolve upstream problems.
Broader context:
Similar situations exist in Canada where health care funding is often inadequate for prevention and promotion strategies, focusing budget on acute care services.
Acute-care services are tertiary prevention measures focused on individual treatment, considered downstream interventions.
Upstream approaches:
Prevention and promotion strategies targeting policy interventions that benefit the entire population.
Emphasis on root causes of preventable diseases and injuries.
Examples of upstream actions:
Advocating for safer environments for recreational activities (e.g., walking, running, biking).
Lobbying for higher tobacco taxes to decrease tobacco usage.
Upstream interventions extend beyond personal behaviors to identify programs, policies, and environmental changes affecting population health.
Policy examples include:
Adding fluoride to municipal water to prevent dental caries.
Adding iodine to salt and vitamin D to milk as health improvement strategies.
Primary Health Care: History of Primary Health Care
Canada is considered an international leader in the health promotion movement, population health, and primary health care (PHC) (CPHA, 2010).
Shortly after Canada became a country in 1867, Canadians began lobbying for improvements to the determinants of health, including:
Safe water and sewage disposal systems
Action on overcrowded and slum housing
Addressing poverty, malnutrition, and unsafe food and milk supplies
In the 1940s, early examples of PHC principles emerged in Canada under Tommy Douglas’s leadership in Saskatchewan:
Concern for the poor’s inability to afford hospital services led to the implementation of a provincial hospital insurance program in 1947.
Elimination of exclusion from health care based on inability to pay for services was the reason for the 1957 national hospital insurance program.
Despite this, people continued to struggle to pay doctor’s fees. Thus, in 1966, Canada instituted a national medicare program to cover costs incurred for treating people in hospitals, clinics, and doctors’ offices (Canadian Health Coalition, 2009).
Health care services are a vital component of PHC. Focusing on needs of the poor was a precursor for future PHC initiatives.
From 1974 to 1994, the Canadian federal government played a significant role in establishing Canada as a leader in health promotion:
The Lalonde Report (“A New Perspective on the Health of Canadians”) was released in 1974 by Marc Lalonde, Minister of Health, which identified four elements of the health field:
Human biology
Environment
Lifestyle
Health care organization
This transformative document shifted national thinking towards health promotion, establishing Canada as a world leader in this field.
ParticipACTION, a notable exercise promotion initiative, originated in the 1970s from the Lalonde Report.
Health promotion programs arising from the Lalonde Report faced under-resourcing issues, concentrating primarily on lifestyle-related initiatives (tobacco, alcohol, drugs, nutrition) without adequately addressing environmental health risks.
Environmental risks identified include the lack of adequate housing and insufficient clothing, creating substantial health threats, not just inadequacies of the health care system (Lalonde, 1974).
The report gained international attention and urged the WHO to address health status disparities between developed and undeveloped countries during a conference in 1978 about PHC which resulted in the Declaration of Alma Ata:
Health is a fundamental human right and attaining the highest health level must include actions from various social and economic sectors beyond health.
Interventions must be practical, scientifically sound, socially acceptable, and universally accessible at an affordable cost.
Community participation at all intervention levels must utilize local resources, including Indigenous health care professionals.
In 1984, the WHO disseminated a discussion document proposing principles of health promotion that engaged the entire population in addressing determinants of health.
In 1985, a Canadian policy review was initiated, leading to the Epp Report, which detailed three mechanisms of health promotion:
Self-care
Mutual aid
Healthy environments (Epp, 1986).
First International Conference on Health Promotion was held in 1986 in collaboration with the WHO and CPHA, resulting in the Ottawa Charter for Health Promotion, cementing Canada’s position as a leader in PHC and health promotion.
Health strategies must expand beyond individual behavior change to include political, economic, social, and cultural interventions promoting empowerment in public policy (Navarro, 2009).
Government roles in health improvement and the collective responsibility of citizens, healthcare professionals, and institutions emphasize a need for collective action against health disparities (Lalonde, 1974).
Historical reluctance by governments to recognize that improvements in socioeconomic conditions are more vital than medical ones is highlighted (Taylor & Rieger, 1985).
Challenges in health promotion remain, with Canadian governments focus on social determinants of health like income, housing, food insecurity, and social exclusion, often failing to adequately address these issues (Muntaner, Ng, & Chung, 2012).
Nurses are encouraged to refocus their practice on social justice, aiming to reduce health and social inequalities, which should be a core competency in nursing (Muntaner et al., 2012).
Recommended policies include initiatives:
To reduce child and adult poverty through financial assistance and social wages
To increase minimum wages to a living wage to support housing and food needs
For campaigns advocating for social rights and intersectoral actions on health inequality
Supporting political candidates promoting social determinant policies
Encouraging workplace democracy to enhance worker bargaining power (Muntaner et al., 2012).
Primary Health Care (PHC) is defined as:
Essential health care based on:
Practical methods
Scientifically sound methods
Socially acceptable methods and technology
Made universally accessible to:
Individuals and families in the community
Through their full participation and at a cost that the community and country can afford to:
Maintain at every stage of their development in the spirit of self-reliance and self-determination.
Forms an integral part of:
The country’s health system, which is the central function and main focus
The overall social and economic development of the community.
Constitutes the first level of contact for:
Individuals, families, and communities with the national health system
Bringing health care as close as possible to where people live and work.
Serves as the first element of a continuing health care process.
Primary Care:
Often confused with Primary Health Care (PHC).
Defined as a narrower concept.
Refers to a person-centred comprehensive approach.
Emphasizes biomedical care delivery at the point of entry into the healthcare system (WHO, 2008).
Example: Nurse practitioners in the community provide primary care services.
Their practices may be informed by values and principles of PHC.
The World Health Organization (WHO) describes Primary Health Care (PHC) as a critical pathway to achieving better health for all.
Five key components essential for reaching this goal:
Reducing exclusion and social disparities in health: This includes initiatives focused on universal coverage reforms to ensure everyone has access to health services.
Organizing health services: Health services must be structured around people’s needs and expectations, known as service delivery reforms.
Integrating health into all sectors: This emphasizes the need to incorporate health considerations across various sectors, which is termed public policy reforms.
Pursuing collaborative models of policy dialogue: Effective leadership reforms require different stakeholders to engage in constructive discussions to shape health policies.
Increasing stakeholder participation: Encouraging greater involvement from all relevant stakeholders is crucial for successful health initiatives (WHO, 2013a, p. 1).
Primary Health Care (PHC) is founded on social justice and equity.
Social justice:
Refers to the fair distribution of society's benefits and responsibilities.
Focuses on eliminating the root causes of inequities (CNA, 2010).
Aims to lead to equality of opportunities for health.
Equity:
Concerns the fair distribution of resources for health.
PHC's philosophical foundation:
PHC is pervasive in all aspects of society.
Charters emphasis on social justice and equity direct nursing focus toward improving health for the most disadvantaged groups.
Ensures all individuals have equal opportunities for health and quality of life.
Strategic focus of PHC strategies:
Developing strengths or assets in communities.
Offering opportunities for change to meet deficits or needs.
Maximizing community involvement as crucial.
Including all sectors that affect the determinants of health, while avoiding duplication of services.
Using health methods and technologies that are accessible, acceptable, affordable, and appropriate for each specific situation (University of Saskatchewan, 2011).
Principles of Primary Health Care (PHC)
Accessibility
Health care is universally available to all individuals, regardless of geographic community.
Services must be delivered in a timely manner.
Distribution of health care providers includes rural, remote, and urban communities.
Barriers to accessibility go beyond geographic barriers and include:
Health care providers’ assumptions or biases against specific groups.
Example: A provider refusing to offer sexually transmitted infection screening to a lesbian couple due to a belief that STIs occur primarily in heterosexual contexts.
Stigmatization of vulnerable populations (e.g., individuals experiencing homelessness, those with addictions, or involved in sex work) in how they are treated in emergency departments.
Individuals feeling discriminated against may avoid seeking health care due to fear of further stigmatization.
Public Participation:
Encourages active involvement of individuals in decisions regarding their own health.
Involves identifying health needs within their communities.
Requires flexibility and responsiveness in healthcare design and delivery.
Emphasizes the importance of respect for diversity in health care approaches.
Health Promotion:
Aims to enhance individuals' understanding of social determinants of health.
Focuses on developing skills that aid individuals in improving their own health and well-being.
Encourages a proactive approach to personal and community health management.
Appropriate Technology: Refers to the suitable modes of care that are aligned with a society’s social, economic, and cultural development.
Equity: A critical aspect of appropriate technology, ensuring that health care resources are distributed fairly among various populations.
Definition: Appropriate technology does not imply that high-technology solutions, such as MRI machines, should be present in every location. Instead, the focus is on creating alternatives to expensive or advanced technological services that are more suitable for many environments.
Development: It is essential to formulate and rigorously test appropriate models of health care before they are put into practice, ensuring their effectiveness and suitability for the intended community.
Intersectoral Collaboration: A vital approach in health and well-being.
Health and well-being are closely linked to economic and social policy.
Establishes national and local health goals and healthy public policies.
Essential for the planning and evaluation of health services.
Collaboration among different health professions is crucial.
Providers from various sectors must work interdependently.
Aim to meet the needs of the public effectively.
Participation in government policy formation is necessary.
Influences health and well-being of individuals in society.
Optimal PHC approaches emphasize full participation of the community members affected.
Community involvement entails:
Development of initiatives.
Coordination of efforts.
Delivery of services.
Evaluation of initiatives.
Participating groups should include:
Laypeople from the community.
Community leaders who can guide efforts.
Practitioners with experience and expertise in PHC implementation.
The WHO has identified eight essential elements of PHC as guiding principles, which help in:
Setting direction for health initiatives.
Measuring success in health promotion.
Education about Health Problems and Prevention Techniques
Education identifies and controls dominant health challenges for a target population.
A solid understanding of Primary Health Care (PHC) and health challenges is necessary to create healthier populations.
Research and application of knowledge occur throughout the health promotion process.
Promotion of Food Supply and Proper Nutrition
Provision of an appropriate and nutritious food supply is essential.
In resource-poor nations, the focus is on providing an adequate food supply.
In resource-rich countries like Canada, strategies focus on obesity and nutrition (Canadian Obesity Network, 2013).
Adequate Supply of Safe Water and Basic Sanitation
Basic sanitation involves the removal of garbage and safe disposal of bodily waste products.
Maternal and Child Health Care, Including Family Planning
Quality health services improve maternal, perinatal, neonatal, and child mortality rates and health outcomes.
303,000 women die annually during pregnancy and childbirth, many of which can be avoided with access to quality care before, during, and after childbirth (WHO, 2016).
Immunization Against Major Infectious Diseases
2 to 3 million deaths per year are averted globally due to immunization.
An additional 1.5 million deaths could be prevented with improved vaccination coverage (WHO, 2018).
Prevention and Control of Locally Endemic Diseases
Endemic diseases are prevalent in specific groups, communities, or regions at relatively low numbers.
Example: Tuberculosis in Northern Canada illustrates the need for a multifaceted PHC approach to eradication (Health Canada, 2012).
Appropriate Treatment of Common Diseases and Injuries
Utilizes the principle of appropriate technology: the right interventions at the right time to meet population needs.
Based on the best scientific evidence and ensuring fair resource use and access based on the local economy.
Provision of Essential Drugs (WHO, 2013b)
Essential drugs sustain and improve life for individuals suffering from acute and chronic illnesses, providing a higher quality of life.
Implementation of PHC Elements:
May be hampered by numerous factors:
Political will: Lack of commitment to health initiatives.
Cultural values:
Including race, age, or gender biases.
Lack of resources: Insufficient funding or materials to support initiatives.
Inadequate infrastructure: Poor physical or social structures to support health care delivery.
Poor Outcomes of PHC Initiatives:
May result from misguided but well-intended decisions.
Decisions often reflect values and norms of the dominant culture, rather than involving the target population.
Involvement at all levels is crucial:
Resource allocation decisions.
Parameters of projects or initiatives.
Canadian Institutes of Health Research (2013):
Developed the Institute of Aboriginal Peoples’ Health.
Goal: Understand and address the significantly worse health outcomes (morbidity and mortality rates) of Aboriginal/Indigenous peoples compared to non-Indigenous Canadians.
Promote innovative research aimed at improving health for Indigenous peoples in Canada.
Research Funding Requirements:
Researchers must demonstrate a good relationship with the Indigenous community.
Includes elements of:
Consultation: Engaging community members in the research process.
Information sharing: Ensuring the community is well-informed about research efforts.
Partnership: Collaborating with Indigenous community members.
Respect: Showing understanding and regard for the community's needs and perspectives
The Ottawa Charter for Health Promotion:
First international conference on health promotion held in Ottawa in November 1986.
212 participants from 38 countries (WHO et al., 1986).
Resulted in the production of the Ottawa Charter for Health Promotion.
Document aimed to be a worldwide charter for action.
Presented strategies and approaches for health promotion deemed vital for:
Major progress toward individual and collective commitment.
Realizing the ambitious goal of “Health for All by the Year 2000.”
Represented a movement toward a “new public health.”
Logo Design: The health promotion logo was created as a representation of the call for action.
Main graphic elements include:
One outer circle
One inner circle
Three wings originating from the inner circle, with one wing breaking through the outer circle.
Key Action Areas for Health Promotion: The logo incorporates five essential action areas:
Build Healthy Public Policy: Health must be prioritized on the agenda of policymakers across all sectors and levels of society, not just the health sector.
Create Supportive Environments for Health: The organization of society (e.g., living and working conditions) needs to be addressed as health is interrelated with other societal goals.
Strengthen Community Action: Community empowerment is crucial, allowing communities to take control over their own actions and destinies, emphasizing community development.
Develop Personal Skills: Enhancing life skills enables individuals to exercise control over their health, requiring both education and action from institutions.
Reorient Health Services: Health services must shift responsibility toward disease prevention and health promotion, promoting collaboration among all citizens to create a health system that supports health pursuits.
Build healthy public policy:
Health must be on the agenda of policymakers across all sectors and levels of society—not just the health sector.
Create supportive environments for health:
The organization of society (e.g., living and working conditions) must be addressed, as health cannot be separated from other societal goals.
Strengthen community action:
Community empowerment is essential for allowing communities to have a greater sense of ownership and control over their own endeavors and destinies.
Community development is a vital part of this strategy.
Develop personal skills:
Enhancing people's life skills enables them to exercise more control over their own health.
Education and institutional action are required for this enhancement.
Reorient health services:
Health services must focus on preventing diseases and promoting health.
The responsibility for health promotion in health services is shared by all citizens; collaboration is necessary to create a health care system that contributes to the pursuit of health (WHO et al., 1986).
Outer Circle:
Represents the goal of building healthy public policies.
Symbolizes the need for policies to "hold things together."
Three Wings Inside the Circle:
Symbolize the need to address all key action areas of health promotion identified in the Ottawa Charter.
Emphasizes an integrated and complementary approach.
Upper Wing Breaking the Outer Circle:
Suggests that society and communities, as well as individuals, are constantly changing.
Indicates that the policy sphere must continually react and develop to reflect these changes for the effective building of healthy public policies.
Inner Circle of the Logo:
Represents the three basic strategies for health promotion:
Enabling:
Strategies that ensure equal opportunity for people to achieve health.
Mediating:
Strategies that mediate among different sectors of society.
Advocating:
Strategies aimed at making social and other conditions favorable for health.
Comprehensive Multi-Strategy Approach:
The logo serves as a visual representation of a coordinated, multi-faceted approach to health promotion.
Health promotion employs diverse strategies and methods in an integrated manner for effective action.
Historical Context of the Logo:
Since 1986, the WHO has retained this symbol as the health promotion logo.
It has experienced some visual modifications over subsequent health promotion conferences, but its essence has remained intact.
Significance of the Ottawa Charter:
The Ottawa Charter continues to be the key policy document of the international health promotion movement.
Its ongoing value has been reaffirmed repeatedly during eight additional international conferences on health promotion.
Other Charters for Health Promotion
Total Global Conferences: To date, there have been nine global conferences on health promotion.
Second International Conference:
Year: 1988
Location: Adelaide, South Australia
Key Assertion: Health was asserted as a human right and a sound social investment;
Therefore, health is a fundamental social goal (WHO, 2009a).
Recommendations:
Encourage people’s involvement in health policy creation.
Promote cooperation between sectors of society (WHO, 2009a).
Third International Conference:
Year: 1991
Location: Sweden
Context: Public concern about global environmental threats had grown, highlighting the need for a focus on sustainable development (WHO, 2009a).
Call to Action:
Address inequities and social justice.
Recognize that millions of people are living in extreme poverty and deprivation within increasingly degraded environments.
Women were particularly highlighted as a population that remains oppressed, facing sexual exploitation and discrimination that hampers their meaningful contribution to creating supportive environments for health (WHO, 2009a).
Education was declared a basic human right and a key catalyst for the political, economic, and social change required to ensure health.
Military Expenditure: Identified as causing not just deaths and disability, but also recognized for contributing to new forms of ecological vandalism (WHO, 2009a).
Fourth International Conference on Health Promotion: 1997, Jakarta, Indonesia
Focus: Health promotion action
Impact on Social Determinants of Health:
Declared a significant influence on improving human rights and reducing health inequities.
Poverty identified as the greatest threat to health (WHO, 2009a).
New partnerships for health required across various sectors:
Partnerships needed at all levels of government and society.
Importance of additional resources:
Focus beyond health sector to include education and housing.
Investment needs:
Must address the needs of vulnerable or marginalized groups:
Examples:
Older people
Children
Women
Indigenous peoples
Populations living in poverty (WHO, 2009a).
Empowering principles emphasized throughout the declaration:
Health promotion is to be done by and with people, not on or to people (WHO, 2009a, p. 20).
Fifth Global Conference on Health Promotion (2000): Held in Mexico.
Resulted in the Mexico Ministerial Statement for the Promotion of Health.
Developed strategies to move ideas into action (WHO, 2009a).
The ministerial statement emphasized:
Promotion of health and social development as a central duty and responsibility of governments (WHO, 2009a).
Critical observation from the conference:
The main issue shifted from a lack of evidence regarding the effectiveness of health promotion.
Identified that the problems were primarily related to political will to change.
Sixth Global Conference on Health Promotion
Held in Thailand in 2005
Led to the Bangkok Charter for Health Promotion in a Globalized World (WHO, 2009a)
Key Affirmations of the Charter
Policies and partnerships to empower communities and improve health and equity should be central to global and national development (WHO, 2009a)
Health promotion is rooted in the critical human right to attain the highest standard of health without discrimination
Recognition of Vulnerabilities
Acknowledgment that the vulnerability of children and exclusion of marginalized populations has increased globally
Highlighting of rising inequities within and between countries (WHO, 2009a)
Challenges Identified
Although progress had been made in placing health at the centre of development, further advancements in
Political action
Broad participation
Sustained advocacy
Many proven-effective health promotion strategies have not been fully implemented (WHO, 2009a)
Seventh Global Conference on Health Promotion (2009):
Held in the Republic of Kenya.
Findings published in “The Nairobi Call to Action” (WHO, 2009b).
Health promotion is affirmed as the core and most cost-effective strategy to improve health and quality of life, and to reduce health inequities and poverty worldwide.
The Ottawa Charter reaffirmed as relevant since 1986 for leading health promotion efforts.
Eighth Global Conference on Health Promotion (2013):
Took place in Helsinki, Finland.
Leaders discussed the implementation of political decisions related to health through practical actions.
Resulted in Helsinki Statement on Health in All Policies emphasizing the need to consider health implications of decisions across government sectors (WHO, 2013b).
Acknowledged implementation gaps in policy, practice, governance, and political will, which lead to avoidable illness and suffering in populations.
Challenges are not due to a lack of evidence of effectiveness of health promotion but stem from deeper issues and mandates driving policies and practices.
Barriers to Health Promotion:
Difficulty in situating health promotion responsibilities beyond the health sector.
Health promotion must extend beyond just promoting healthy lifestyles to include comprehensive social change.
Health agenda must be prioritized by policymakers, governments, social and economic sectors, industries, and media, as stressed in the Ottawa Charter.
Navarro (2009) Analysis:
Attributes lack of progress in health promotion to neo-liberal government policies that exacerbate class dominance and alliances based on power.
Results in continued poverty as a major determinant of health across countries.
Emphasizes the need to recover representativeness of political institutions and hold them accountable to disenfranchised populations, viewing disease as a social and political issue.
Rudolf Virchow:
Surveyed the 1848 typhus epidemic contracted by Polish government and stated, “Medicine is a social science, and politics nothing but medicine on a grand scale” (Taylor & Rieger, 1985).
Recommended improvements in income, employment, housing, and nutrition, along with political reforms concerning democracy, education, and taxation.
His recommendations were deemed unacceptable by the government, resulting in his suspension in 1849.
Ninth Global Conference on Health Promotion (2016):
Held in Shanghai, China, focusing on a vision aligning with the United Nations 2030 Sustainable Development Goals (SDGs).
Health promotion designated as a key means for achieving global sustainable development.
Investments in health promotion expected to create societal transformations beneficial to disadvantaged populations while improving overall health and quality of life (WHO, 2017).
Conference Outcomes:
Described as a “political watershed” for health promotion.
Over 1260 high-level political stakeholders engaged, stressing the necessity of bold political action.
Health framed as a political issue, making political choices and commitments essential.
Thematic areas of focus included good governance, healthy cities, and health literacy (WHO, 2017).
Attendance by over 100 mayors to discuss initiatives for creating healthy cities within the context of the SDGs.
Social Determinants of Health: Variations in the Literature
The concept of social determinants of health has its origins in the Lalonde Report, which discussed the impact of physical and social environments.
The definition was expanded upon in 1996 by Tarlov, incorporating key factors such as:
Housing: Affects living conditions and overall well-being.
Education: Influences health literacy and access to health resources.
Social acceptance: Affects individuals' feeling of belonging and mental health.
Employment: Provides economic stability and social structure.
Income: Directly correlates with access to healthcare and healthy living conditions.
These determinants were developed to understand disparities in health outcomes among socioeconomic groups (Raphael, 2009).
The Canadian Nurses Association (CNA) emphasizes the importance for nurses to assess multiple factors influencing clients’ health.
For example, in workplace hierarchies:
Individuals in lower workplace positions are three times more likely to die from health issues such as heart disease, stroke, cancer, gastrointestinal disease, accidents, and suicide compared to those at the higher levels of the hierarchy.
These disparities cannot solely be attributed to differences in medical care (CNA, 200
Understanding the Connection
Nurses must be aware that serious illness and early death related to poverty areconnected to low social standing.
Poor health and early death are linked to social determinants of health, not just toaccessibility to health care.
Negative Effects of Poverty
Poverty has a huge negative effect on health, impacting various social determinants, such as:
Social environments
Social support networks
Educational attainment
Gender
Employment status
Income and social status
Findings from Stewart et al. (2009)
Social isolation and perceptions of belonging compared between low-income and higher-income individuals in Canada.
Low-income individuals:
Experience greater isolation
Have a lower sense of belonging
Poverty is tied to feelings of being:
Prejudged
Stigmatized
Avoided
Isolated
Such feelings prevent engagement in community activities, leading to increased distancing and self-isolating behaviors.
Impact of Internalized Processes
The marginalizing process enhances feelings of disempowerment and worthlessness.
This can lead to detrimental effects on emotional, mental, and physical health.
Recommendations by Stewart et al. (2009)
Suggests that programs and policies addressing the root causes of poverty can:
Help increase a sense of belonging.
Decrease social isolation of vulnerable populations.
Children's Health and Poverty
Children’s health is notably impacted by poverty.
Living circumstances affect children’s health immediately and also influence their health status as adults (Raphael, 2010b).
Social Determinants of Health
Various Authors' Contributions:
Different authors have added to or modified the social determinants of health.
Public Health Agency of Canada (PHAC):
Retained 12 determinants from the Population Health Promotion Model (PHPM).
Expanded on some determinants:
Education and Literacy
Employment or Working Conditions
Personal Health Practices and Coping Skills
Biology and Genetic Endowment (PHAC, 2011).
Chief Public Health Officer’s Report (Butler-Jones, 2012):
Identified key determinants of health factors:
Income and Social Status
Social Support Networks
Education and Literacy
Employment and Working Conditions
Social Environments
Physical Environments
Personal Health Practices and Coping Skills
Healthy Child Development
Biology and Genetic Endowment
Health Services
Gender
Culture
These determinants impact Canadians throughout their life course.
Notably similar to the original 12 determinants listed in Figure 8.2.
Emerging Determinants:
Newer additions have brought specific areas into focus:
Housing
Indigenous Background
Further considerations include War or Conflict and Hope as determinants for future assessment in health.
Raphael’s Contribution (2016):
Suggested a total of 16 social determinants of health:
Disability
Early Life
Education
Employment and Working Conditions
Indigenous Ancestry
Food Security
Gender
Geography
Housing
Health Care Services
Immigrant Status
Income and its Distribution
Race
Social Safety Net
Social Exclusion
Unemployment and Employment Security
Emphasized that Indigenous Ancestry is underexplored and essential to understanding health outcomes.
"Represents the interaction of culture, public policy, and the history of colonialism and systematic exclusion affects health" (Raphael, 2016, p. 10).
Statistics Canada Report (2016):
Examined the relationship between social determinants of health and health outcomes for off-reserve Indigenous populations aged 15 and older.
Utilized data from the 2012 Aboriginal Peoples Survey.
Health outcomes analyzed through three perspectives:
Proximal Factors: Health behaviours, physical and social environments.
Intermediate Factors: Community infrastructure, systems, and resources.
Distal Factors: Historical, political, social, and economic contexts.
Key Intermediate and Distal Factors predictive of poor health outcomes included:
Living in a home needing major repairs
Having less than high school education
Being unemployed
Household income in the lowest tercile
Experiencing food insecurity
Lacking a support network (no one to turn to for support) (Statistics Canada, 2016).
Toronto Charter on the Social Determinants of Health:
National conference "Social Determinants of Health across the Lifespan" held at York University, Toronto, 2002.
Focused on discussion and analysis of the state of social determinants of health in Canada.
Resulted in the Toronto Charter on the Social Determinants of Health (Raphael, 2009).
Key Differences from PHPM Determinants:
Identification of Aboriginal status as a separate determinant due to related poor health outcomes.
Issues of food security and housing recognized as stand-alone determinants.
Vulnerable Populations:
Canadian women, Canadians of colour, and new Canadians identified as at greater risk when there is deterioration in determinants of health (Raphael, Bryant, & Curry-Stevens, 2004; "Strengthening the Social Determinants of Health", 2003).
Proposed Social Determinants:
12 determinants of health were proposed in the Toronto Charter (see Table 8.1).
Community Health Nurses of Canada (CHNC) expanded to 27 determinants (CHNC, 2019, revised).
Potential additional determinants include mental health and obesity (International Association for the Study of Obesity, Canadian Obesity Network, & Centre for Addiction and Mental Health, 2012).
Action Strategies and Advocacy:
Toronto Charter for Physical Activity (GACPA & ISPAH, 2010) promotes the creation of environments supporting physical activity.
Advocates for:
Well-being and mental health.
Prevention of disease.
Improvement of social connectedness and quality of life.
Economic benefits and environmental sustainability.
Impact of Physical Activity:
Identified as a powerful method to decrease non-communicable diseases and enhance health worldwide.
Lack of physical activity is linked to various diseases (heart disease, stroke, diabetes, cancers), and is the fourth leading cause of death globally.
Complex factors influencing physical inactivity necessitate multi-sectoral approaches for solutions.
Recommended Investments:
Seven "best investments" proposed to uplift population levels of physical activity.
Conclusion:
Active collaboration of governments, organizations, and communities is crucial to foster environments that promote physical activity and improve health outcomes for all Canadians.
Whole-of-school programs:
Advocates for highly active activities for children.
Provides opportunities for staff and families to participate in physical activities.
Transportation policies and systems:
Prioritize walking, cycling, and public transportation.
Helps to improve air quality and ease traffic congestion.
Urban design regulations and infrastructure:
Provide equitable and safe access to recreational physical activity.
Facilitate transport-related walking and cycling for people across the life course.
Physical activity and non-communicable disease prevention:
Integrated into Primary Health Care (PHC) systems.
Health care workers, including nurses and physicians, can screen for potential issues.
Educate a large portion of the population on the importance of physical activity in daily life.
Public education:
Utilizes mass media to raise awareness and change social norms regarding physical activity.
Community-wide programs:
Involves multiple settings and sectors.
Mobilizes and integrates community engagement and resources.
Whole-community approaches are more successful than single-program delivery approaches in encouraging physical activity.
Sports systems and programs:
Promote “sport for all” to encourage participation across the lifespan.
Adapt sports programs to reduce financial and and social barriers; to appeal to women, men, girls, and boys of all ages; and to be accessible and inclusive for people with mental and physical disabilities (GACPA & ISPAH, 2010)
Jason's Hospitalization:
Jason is in the hospital due to a bad infection in his leg.
The infection occurred because he has a cut on his leg that became infected.
Circumstances Leading to Injury:
The cut happened while Jason was playing in a junk yard next to his apartment building.
The junk yard contained sharp, jagged steel, which he fell on.
Neighborhood Conditions:
Jason plays in the junk yard because his neighbourhood is run down.
The area has many kids with no supervision, leading to unsafe play conditions.
Family Background:
Jason's family lives in that neighbourhood because his parents can’t afford a nicer place to live.
Financial struggles are partly due to his dad being unemployed.
Educational and Employment Factors:
His father's unemployment is linked to his lack of education, which prevents him from finding a job
Jason’s Story Overview
Illustrates the cascade of societal inequities contributing to a young boy’s injury and hospitalization.
Highlights that the health of Canadians may be shaped more by societal values than by individual lifestyle and behavior.
Key Question:
Should ask, “Why is there a junkyard and not a safe playground in Jason’s neighborhood?” instead of “Why doesn’t Jason play somewhere else?”
Impact of Environment on Health
Conditions where we live, work, and play directly affect psychological and physical health.
Affects families, friends, neighbors, and the broader community (Mikkonen & Raphael, 2010).
Role of Education and Employment
Lack of post-secondary education restricts individuals like Jason’s father to working minimum wage jobs.
Limited income affects options for affordable living.
Low-cost housing is often located in high-density areas lacking safe green spaces and parks for children and families.
Determinants of Health
Health of Canadians is largely determined by social conditions, which include:
Distribution of income and societal wealth
Affordable post-secondary education
Employment status and working conditions
High-quality affordable housing
Safe neighborhoods
Availability and accessibility of health care and affordable medications
Social services availability during times of need (Mikkonen & Raphael, 2010).
Nursing Actions for Health Promotion
Important for nurses to address the root causes of poverty and an unjust society (Lind, Loewen, & Mawji, 2012).
It is ineffective to simply tell Jason to play somewhere else when his environment offers no other options.
Highlight the need for societal support in making living environments healthier (Frankish et al., 2006).
Community Health Nurses (CHNs):
Play a crucial role in advocating for and supporting vulnerable communities.
Focus on self-empowerment and creating change through social action.
CNA's Encouragement:
The Canadian Nurses Association (CNA) encourages all nurses to support the health of society.
Focus on promoting public policies that address the social determinants of health.
Advocacy Role of Nurses:
Nurses are in a significant position to act as advocates.
They have more contact time with the population than any other health care professionals (Mildon, 2013a).
Importance of Contact Time:
The extensive contact time allows nurses to build rapport and understand community needs better.
Their educational preparation enhances their ability to advocate effectively.
Wealth of Experience and Knowledge:
Nurses possess a collective wealth of experience and knowledge.
This education and experience equip them to identify health issues within communities.
Participation in Health Research:
By engaging in health research, nurses can contribute to the understanding of the relationship between social determinants and health in Canada (CNA, 2009).
This research enables nurses to inform their practice as agents of social change.
Changing Unhealthy Environments:
Efforts to change unhealthy environments and social conditions can lead to improved health outcomes.
Reducing stories like Jason’s can be a result of addressing these fundamental issues.
Canadian Nurses Association (CNA): Role in the Social Determinants of Health
In 2011, CNA president Judith Shamian and staff attended a commemorative event in Ottawa celebrating 25 years of the Ottawa Charter.
Meeting with pioneers:
Irving Rootman (Canada)
David McQueen (USA)
Ilona Kickbusch (Europe)
Leaders described the impact of the Ottawa Charter:
Changed the definition of health care to focus on social justice.
Offered three challenges to global health professionals:
Focus on social determinants of health to build capacity for health promotion in individuals, communities, and society.
Reaffirm commitment to a more equitable world.
Encourage investment in public health through public support and collaboration beyond the health sector with education and private industry (Ashley, 2011).
Opportunities for Nurses:
Reduce social inequalities and inequities, positively influencing the health of Canadians through:
Engaging in politics and policy analysis.
Acting as advocates for marginalized and disadvantaged groups to access services addressing multiple determinants of health.
Ensuring access leads to positive benefits for the quality of health and living.
Examples of Nursing Actions:
Support initiatives to decrease childhood and adulthood poverty by increasing:
Financial assistance and social wages provided through public funds.
Support initiatives to raise minimum wages to living wages ensuring:
Economic security
Stable housing
Food security
Support campaigns advocating for:
Progressive taxation (based on income)
The right to food security and affordable housing
Enforcement of laws protecting rights of socially excluded groups
Advocate for intersectoral action on health at various government levels (municipal, provincial, federal) to coordinate actions outside the health sector.
Support political parties receptive to action on social determinants of health, particularly those that are pro-labour and advocate for wealth redistribution.
Encourage greater workplace democracy to increase unionized workplaces as they contribute to:
Generous welfare states
Narrower social inequalities
Better population health (Muntaner et al., 2012).
To address health inequalities and the social determinants of health for all Canadians, the CNA (2012) recognizes:
The need for nurses to advocate for improvements in social determinants of health approaches.
Focus on addressing the disparities in physical and mental health outcomes for Canadians across the lifespan.
The profession of nursing has:
A vast body of knowledge and experience.
The potential to offer a strong and powerful voice for change.
Large numbers make up the largest group of health care professionals in Canada.
Nurses have:
A professional and social responsibility to become a significant part of reshaping Canada’s health care system.
A responsibility to ensure the system addresses the social determinants of health for all Canadians.
An obligation to not just stand by and watch the restructuring that focuses on meeting the requirements of institutions (CNA, 2012).
POPULATION HEALTH PROMOTION
Health promotion involves a comprehensive, multi-strategy approach, applying diverse strategies and methods in an integrated manner.
This characteristic is one of the preconditions for health promotion to be effective.
Health promotion addresses the key action areas identified in the Ottawa Charter in an integrated and coherent manner.
Population health promotion is a process of taking action on the interrelated conditions (i.e., social determinants of health) that affect a population’s health to create healthy change.
Focus:
Maintaining or improving the health of populations
Reducing disparities in health status between people, especially those with inadequate income
In population health promotion, concepts are integrated with the principles that guide action on health promotion.
The PHPM (Population Health Promotion Model, Flynn, 1999) explains the relationship between population health and health promotion.
It illustrates how a population health approach can be implemented through action on the full range of health determinants by using multiple health promotion strategies outlined in the Ottawa Charter for Health Promotion.
Evidence in Health Promotion:
Debate exists regarding the use of evidence in health promotion practice.
A solid evidence base for health promotion practice exists (Juneau et al., 2011).
If a narrow view of evidence (e.g., rigid empirical research) prevails among practitioners, the evidence base may seem limited.
Expanding the view to include multiple styles of research reveals a wealth of evidence practitioners can utilize.
Current Trends:
Shift from individual-centered health promotion interventions to those targeting groups or entire populations.
This reflects a shift towards environmental and social justice-oriented health promotion (Juneau et al., 2011).
Local Relevance:
Emphasis on the importance of local relevance in planning health promotion.
Participatory research projects are emerging as effective examples for improving local interventions (Potvin et al., 2011).
This new approach holds promise, contrasting previous attempts to change individual behavior with limited long-term success.
Health Promotion vs. Public Health:
Health promotion is described as the best link to social justice, social change, and social reform through its focus on reducing disparities impacting health.
As stated by Marie-Claude Lamarre (2011), health promotion is a multi-dimensional, cross-sectoral concept.
Key Values and Principles:
A socioecological model of health that considers cultural, economic, and social determinants of health.
A commitment to equity and social justice.
A respect for cultural diversity and sensitivity.
A dedication to sustainable development.
A participatory approach for engaging the population in identifying needs (Lamarre, 2011, p. 3).
Population Health Promotion Model (PHPM)
Developed: 1996 by Nancy Hamilton and Tariq Bhatti, revised by Larry Flynn in 1999.
Model Type: Canadian-developed model represented visually as a cube.
Purpose of PHPM
Understand the who, what, how, and why of interventions on multiple levels to create healthy change.
Key Components
Determinants of Health:
Understanding extends beyond genetics or biology.
Importance of understanding people's needs.
Development of action strategies for promoting health.
Evidence-Based Decision Making
Decisions guided by:
Research
Evaluation
Experiential Learning
Values and Assumptions
This forms the foundation of professional decision-making, shaping potential interventions.
Values and Assumptions in PHPM
Comprehensive action needs to be taken on all determinants of health.
Multiple entry points for planning and implementation are essential.
Health problems may disproportionately affect certain groups.
Solutions require changing social values and structures.
Individual health results from health practices and impacts of social and physical environments.
Health-promoting opportunities arise in environments with social justice and equity.
Building relationships based on mutual respect and caring is crucial.
Meaningful participation of community members is essential.
Self-Understanding
Recognizing one's own values and assumptions opens pathways to listen to and value other perspectives.
Enables true partnerships and authentic inclusion.
Addressing Root Causes
PHPM suggests focusing on the most powerful interventions for creating healthy change.
Considers social determinants of health, encompassing economic and social conditions that affect health.
Conclusion
Health problems may vary in impact across groups.
Emphasizes societal responsibility for addressing and solving health issues, which may require changes in social values and structures.
PHPM Structure:
The Population Health Promotion Model (PHPM) is represented as a four-sided cube.
Sides of the Cube:
Social Determinants of Health
Levels of Action
Action Strategies
Foundations of the Cube
Purpose of the Model:
The intent of this model is to guide actions to improve health by addressing the following questions:
On what should we take action?
How should we take action?
With whom should we act? (PHAC, 2001)
Social Determinants of Health:
The determinants consist of:
Income and Social Status
Social Environments
Work and Working Conditions
Education
Social Support Networks
Genetic Endowment
Personal Coping Skills
Health Services
Healthy Child Development
Culture
Physical Environments
Gender
Levels of Action:
This cube side highlights the need for action at various levels within society, including:
Individual Level
Family Level
Community Level (linked by a common interest or geographic setting)
Structural/System Level (e.g., housing or education sectors)
Societal Level (PHAC, 2001)
Action Strategies:
The Action Strategies side includes a comprehensive set derived from the Ottawa Charter.
Foundations of the Cube:
The base of the model provides a foundation that gives direction for action on population health grounded in:
Evidence-Based Decision Making
Research
Evaluation
Experiential Learning
Values and Assumptions
Population Health:
Approach used to understand and improve the health of an entire population or subpopulations (e.g., children, older adults, newcomers to Canada).
Linked to health promotion that focuses on the root causes of health issues, rather than individual health.
Identifies and takes action to improve health determinants impacting the overall population (PHAC, 2013a).
Health Inequities:
Addressed through research to determine factors influencing health at the population level.
Develops, implements, and evaluates strategies targeting modifiable risk factors (Vollman, Anderson, & McFarlane, 2017).
Factors Influencing Population Health:
Typically interrelated conditions occurring over the life course.
Past interventions contribute to measurable improvements in population health.
Population Health Indicators:
Used for measuring the health of populations and the progress toward creating healthier citizens.
Closely related to the determinants of health.
Examples of health indicators include:
Self-rated well-being surveys
Life expectancy
Specific diagnoses or types of injury (e.g., lung cancer, hip fractures)
Hospitalization days per diagnosis
Death rate
Potential years of life lost
Emergency room visits (number and reason).
Data Collection:
Measurement indicators are collected annually.
Allows health care professionals to compare data, track changes, and identify success and areas for improvement.
Health status indicators found in Statistics Canada publications, community health profiles, census data, and health indicator reports (Health Canada, 2017).
Population Health Assessment:
Additional information on protective factors and risk factors specific to a population is necessary (Kindig & Stoddart, 2003; Vollman, Anderson, & McFarlane, 2017).
Assessments may include:
Levels of physical activity
Breastfeeding practices
Diet
Tobacco use
Alcohol and illegal drug usage
Living and working conditions
Number of crosswalks and safe places to cross busy streets
Schools and their entrance requirements
Number and condition of playgrounds and green spaces
Presence of recreational centres
Pollution levels
Environmental scans summarize changes or noteworthy data in health status indicators and include current and emerging issues.
Population Health Interventions:
Include policy and program development to address social, economic, and physical environment factors that influence people's decision-making (Hawe & Potvin, 2009).
May begin by obtaining information from other health providers about past successful and unsuccessful strategies.
Information gathered from:
Online searches
Literature reviews
Key informant interviews
Aim to prevent duplication of unsuccessful interventions and encourage building on successful ones.
Framework: The population health approach coupled with the Population Health Promotion Model (PHPM) (Flynn, 1999) provides a framework to plan how to target population health and develop interventions.
Identified Population:
Could be geographically located or an aggregate of people sharing commonalities, such as:
Age
Interests
Diagnosis
Culture
Religious affiliation
Population health interventions may be implemented at community, sector, or societal levels.
Strategies:
Strategies developed to change population health are generally different from those used for individuals.
Development of personal skills at a population level facilitated by social marketing interventions, including:
Use of websites
Advertisements (bus, billboard, television)
Radio interviews or newspaper columns
Many people do not change behaviour solely based on knowledge of what is best for their health.
Example: Smokers may recognize that smoking is harmful, yet continue due to addiction.
Action Strategies:
To improve population health, multiple strategies frequently include:
Building healthy public policies that legislate healthy behaviour (e.g., tobacco bylaws, seat-belt laws, speed limits).
Creating supportive environments (e.g., tobacco cessation programs, soft playground surfaces, safe bike paths).
Challenges in Population Health Strategies:
Developing and implementing successful population health strategies is challenging.
Health care professionals may know the social, economic, and physical forces affecting health concerns.
Achieving health promotion goals can take years.
Requires multiple health promotion strategies at various levels (individual to societal).
Example: Tobacco Cessation Initiatives
Tobacco identified over 60 years ago as a cause of lung cancer.
1959: The Canadian Public Health Association (CPHA) began an anti-tobacco educational campaign targeting smokers.
Strategies Implemented Over the Decades:
Building Healthy Public Policy:
Increasing taxes on tobacco to make it less affordable for children and teens.
Penalties for selling tobacco products to those under 18 years.
Lobbying resulted in bylaws decreasing secondhand smoke exposure.
Banning tobacco advertising.
Developing Personal Skills:
Campaigns to raise awareness about the dangers of tobacco use.
Providing strategies to assist smokers in quitting.
Targeted Strategies for high-risk groups:
Reorient health services to provide more cessation services.
Strengthening community groups to create environments where smoking is less convenient.
Social marketing campaigns to de-normalize smoking.
Outcomes in Canada:
Significant decrease in smoking rates.
2011 data: 22.3% of males and 17.5% of females smoked.
Need for further population interventions: In 2008, there were 19,000 lung cancer deaths in Canada, constituting around 27% of all cancer deaths.
Social Marketing in Health Promotion
Definition: Social marketing is a term introduced in 1971 to describe the use of marketing principles and techniques to advance a social cause, idea, or behaviour (Kotler & Roberto, 1989).
Strategy: It employs proven concepts and techniques from the commercial sector to promote changes in social behaviours.
Goal: The primary aim is to encourage health-promoting behaviours, or to eliminate or significantly reduce behaviours that negatively impact a population’s health.
Health Intervention Approach: Described as a health intervention approach (Gordon, McDermott, Stead, & Angus, 2006).
Potential: When used appropriately, social marketing holds enormous potential to create healthy change and influence social issues (Andreasen, 1995).
Examples of Successful Campaigns
Notable long-running social marketing campaigns include ParticipACTION, which focuses on exercise promotion.
Other campaigns aim to:
Increase breastfeeding
Decrease unprotected sex
Effectiveness of Social Marketing
Most effective for populations considering change or those who have been unsuccessful in making changes.
Particularly useful for improving the health of communities or populations that are hard to reach via other methods.
Example: Easier to intervene with children in schools (a "captive audience") than with working adults.
Difference from Education Campaigns
Social marketing campaigns are not merely education campaigns aimed at creating awareness of an issue.
Objective: To promote socially beneficial behaviour change (Grier & Bryant, 2005).
Limitations and Considerations
Caution: Social marketing may not always be appropriate, especially for people who actively resist change or are entrenched in particular behaviours.
Alternate Strategies: Legislative interventions may be necessary (e.g., laws enforcing seat-belt use) to achieve desired health outcomes.
Six Essential Benchmarks of a Successful Social Marketing Intervention (Gordon et al., 2006):
Voluntary Behaviour Change
Involves measurable objectives for tracking success.
Consumer Research
The intervention should be derived from understanding consumers’ values and needs.
Segmentation and Targeting
Consider different variables to select more focused target groups.
Marketing Mix (Four Ps)
Uses the following components:
Product: The idea or behaviour that is promoted.
Price: The cost associated with adopting the behaviour.
Place: Where the product or message is delivered.
Promotion: Strategies for effectively promoting the health idea.
Exchange
Ensures the target group feels they receive a reward (tangible or intangible) for engaging.
Competition
Identifies competing behaviours and develops strategies to reduce their impact on the targeted behaviour change.
Preparation for Social Marketing Strategy:
Nurses must have a clear understanding of the target audience.
Identify the specific behaviour to change or adopt.
Develop a clear and concise statement of the desired change.
Challenges in Health Promotion Practice:
Health promotion practitioners often have multiple important messages to deliver.
Determining which message has the highest priority for achieving measurable change can be challenging.
Key Question for Practitioners:
“If the target population follows the suggested action, will I achieve my program goal?”
Principles of Social Marketing:
Based on the four Ps from commercial marketing:
Offering the Right Product
At the Right Price
Presented at the Right Time and Place
Promoted Effectively
The product may include social practices or tangible objects aimed at improving health (e.g., weight loss or tobacco cessation programs).
Call to Action:
An effective call to action provides specific steps for individuals to take, such as offering a phone number for assistance, rather than merely suggesting a behaviour change.
"At Risk" Populations
Definition:
"At risk" refers to a group or population with a higher risk of particular illness (morbidity) or negative life outcomes (mortality) compared to other populations (Kozier et al., 2014; Roach, 2000).
Implications of Labeling:
This term can provide awareness for prevention efforts, but can also lead to stigma such as:
Racism
Sexism
Ageism
Other prejudices
Such stigmas can affect health care professionals' assumptions and treatment of at-risk populations, fostering oppressive behaviors.
Social Assistance Recipients:
Common stereotype: recipients are lazy and choose unemployment.
If health care practitioners embrace this stereotype, they may:
Discriminate against these individuals when creating care plans.
Minimize their access to competent and compassionate health care.
Indigenous Peoples:
Indigenous populations face additional stigmas in health care:
Higher rates of morbidity (e.g., diabetes) and mortality (related to disease and suicide) among Métis, First Nations, and Inuit.
Problems are often viewed as individual deficits rather than a reflection of broader social and historical inequities (Adelson, 2005).
Discriminatory practices related to racism contribute to an unsafe health care system for Indigenous people (Health Council of Canada, 2012).
Consequences of Assumptions:
Dangerous assumptions can exacerbate stigma:
If excess mortality is viewed as an intrinsic characteristic, it could be misconstrued as a sign of racial inferiority (Roach, 2000).
Refusal to recognize the social injustices (like racism, discrimination, poor education, and underemployment) as contributing factors can result in significant moral and financial implications (Roach, 2000).
Labeling a group as "at risk" has dual implications:
Positive Outcomes:
Brings attention to and addresses the causes of health inequities.
Consideration of longer-term risk exposure.
Provides easier access to resources to address health issues.
Attracts public and political attention and support to the issue.
Negative Outcomes:
May further marginalize and stigmatize the group.
Expands societal assumptions of incapacity or incompetence.
Justifies oppressive practices against the group.
Can lead to nurses making paternalistic assumptions, ignoring the group’s decision-making capabilities and voice.
Traditional research approaches for labeled groups often include:
Interventions focusing exclusively on requiring individuals to learn facts and change their own high-risk behaviors.
These interventions are often less successful than those targeting government regulation or direct action, such as:
Clean water
Adequate sewage
Housing standards
Highway safety
Occupational safety
The Multiple Risk Factor Intervention Trial (MRFIT):
Described as a failure by its lead researcher, Syme.
A multimillion-dollar randomized control trial in 20 cities in the U.S.
Aimed to reduce the death rate from heart disease in men by promoting behavioral changes.
Interventions targeted 6428 men, focusing on:
Tobacco reduction
Diet change
Control over hypertension
Participants were followed by clinic staff and counselors for six to eight years.
Results showed no significant difference in outcomes between intervention and control (non-intervention) groups.
Conclusion by Syme:
Health promotion must shift focus from individuals to addressing societal forces driving health issues.
Stated, "In trials like MRFIT, nothing is done to change the distribution of disease in the population because such programs do not address the forces in society that caused the problem in the first place."
Concluded that social, economic, organizational, or political situations are at the root of most health problems.
Highlighted the importance of empowering individuals as a critical first step in societal change.
Risk Communication
Involves the transmission of information regarding:
Existing or imminent health or environmental risks
Anticipated severity of the risk
Percentage of the population it will impact
Vital importance due to rapidly changing risks in the current social environment caused by:
Introduction of new and varied technologies
Timely information is crucial:
Most influential factor in shaping decision-making and subsequent behavior
Communication must be:
Strategic
Appropriate for the target audience
Grounded in evidence from both social and physical sciences (Health Canada, 2006)
Contact tracing is a specific form of risk communication discussed in Chapter 12.
Risk Management
Refers to a broad collection of activities aimed at addressing health or safety risks
In health promotion, it helps identify subpopulations with unique health concerns or similar risk factors:
Groups may share social, cultural, economic, or geographic commonalities
Targeting risk factors effectively for specific populations, rather than using a generalized approach:
Generalized approaches may be too diluted and ineffective for creating measurable change
More amenable to implementing diverse strategies to address multiple determinants of health
Easier to identify and involve community leaders for evaluation
Example: Smoking cessation strategies targeting pregnant women rather than the general population.
Health Promotion: Nurses expand their focus beyond disease prevention to include injury prevention, aiming to promote the health of individuals, families, and communities.
Prevention Interventions can occur at five levels:
Primordial Prevention (distal level)
Primary Prevention (proximal level)
Secondary Prevention
Tertiary Prevention
Quaternary Prevention (Starfield, 2001; Vollman et al., 2017).
Primordial Prevention:
Prevents risk factors from existing.
Focuses on avoiding illness or injury by addressing issues at a distal level before they become risk factors.
Involves identification of potential risk factors and mobilization of policy and public awareness to avert injury or illness.
Primary Prevention:
Risk factors may exist; focuses on interventions to prevent or reduce the risk of disease or injury at a more proximal level.
Emphasis on health promotion activities targeting specific populations.
Examples of Primordial Prevention:
Removing access to tobacco products and smoke from public venues (McPherson et al., 2017).
Nursing Interventions at the Primary Prevention Level:
(a) Promote properly installed CSA-approved car seats for transporting newborns.
(b) Offer smoking cessation programs.
(c) Conduct public education to help stop the spread of sexually transmitted infections (STIs) in all age groups.
Additional initiatives include ensuring safe housing, sanitation, and nutrition.
Immunizations against childhood diseases, along with mass immunization clinics for influenza, are crucial (CHNC, 2012).
Historical Context:
Spanish Influenza Epidemic (1918-1919) resulted in approximately 2 million deaths worldwide.
In Canada, the death toll during the epidemic reached 50,000, starkly contrasting the 60,000 deaths from four years of war.
Many victims were young and healthy individuals who succumbed rapidly after contracting the virus.
Non-essential services ceased, quarantines were enforced, and face masks became mandatory in public spaces during the epidemic.
Following this crisis, a department of health was established in Canada in 1919 (Canadian War Museum, n.d.).
Value of Primary Prevention:
Yearly mass immunizations against influenza have been vital in preventing future epidemics.
Primary prevention actions have also minimized the spread of preventable childhood diseases and reduced risks associated with car crashes and many communicable diseases.
These efforts support and preserve the overall health of Canadians.
Secondary Prevention
Focus:
To halt an illness if possible or effect a cure, or at least slow the progression of a disease through therapeutic treatments and medications.
Examples of Secondary Prevention:
Screening measures:
Examine skin for signs of melanoma.
Blood tests for diabetes.
Testicular self-exam.
Yearly cholesterol tests.
Colonoscopies.
Papanicolaou (Pap) smear:
Used for early detection of cervical cancer.
Routine use has decreased women's deaths from cervical cancer by over 70% since the 1950s (Daley et al., 2013).
Blood Pressure Machines:
Available in communities (e.g., grocery or drug stores).
Allows individuals to actively monitor their cardiovascular health.
If an unusual reading occurs, individuals can arrange for thorough assessment by a health care provider, potentially preventing damage from undetected and untreated hypertension.
Tertiary Prevention
Goal:
To limit disability and rehabilitate or restore affected persons to their maximum capability, maximize quality of life, and meet self-identified goals.
Examples of Tertiary Prevention:
Rehabilitation for stroke victims.
Counselling for victims of rape.
Nursing Role:
Identify potential complications.
Implement strategies considering vulnerabilities, strengths, and preferences.
Provide education, monitor treatment effectiveness, and address adverse side effects.
Example in Disaster Situations:
In events like the 2013 Calgary floods, CHNs may:
Provide door-to-door first aid.
Offer emotional support.
Educate on safety and sanitation.
Assess individual and family needs.
Connect people with necessities like housing, food, and medications.
Community-level interventions include collaborating with partners to restore community functionality.
Quaternary Prevention
Focus:
Identify people at risk for medical mishaps, such as untested treatments or over-medicalization.
Aim to address issues related to patient safety and the necessity for evidence-informed decision making.
Ethical Practices:
Examine unnecessary investigations or treatments that may lack benefit or create harm.
Involve affected individuals and society in evaluating health issues.
Example at the Population Level:
Recognizing trauma in populations affected by natural disasters and minimizing over-exposure to health assessments or research.
Harm Reduction:
A philosophy and approach to health care delivery, programs, or policies.
Goal: Protect the health of individuals engaging in high-risk activities associated with poor health outcomes.
Not focused on cessation of high-risk behaviour, but on reducing immediate and related harms.
Access to Information:
Ensures access to evidence-based information for informed decision-making regarding health.
Promotes equal access to health care services.
Nonjudgmental Stance:
Focuses on reducing potential harm while treating individuals with respect and dignity.
A health-promoting strategy that provides specialized health care services to address concerns and minimize negative health outcomes.
Challenges Accessing Health Care:
Individuals may face obstacles such as negative past experiences or fear of judgment.
Addressing Health Inequities:
Aims to bring meaningful health care to marginalized individuals that may be overlooked by traditional health care providers.
Ensures equitable access to health care, counselling, and social services for marginalized persons.
Meeting People Where They Are:
Harm reduction is about providing nonjudgmental, compassionate care aimed at reducing secondary harm from high-risk behaviours.
Examples of High-Risk Behaviours Addressed:
Illegal and prescription drug abuse, unsafe sexual activities, and exposure to secondhand tobacco smoke.
Promoting Health:
Providing at-risk individuals with products and health care services while they engage in harmful behaviours promotes health and reduces negative health outcomes.
Ensures the universal right to health care is accessible to marginalized Canadians.
Social Determinants and Justice:
Acknowledges complex relationships between root causes, social determinants of health, social justice, and health inequities across socioeconomic groups.
Public Health Benefits:
Harm reduction helps control the spread of communicable diseases:
Example diseases: HIV, hepatitis C, STIs, and preventable lung diseases.
Tobacco smoke poses risks to smokers and bystanders when not regulated.
Tobacco Harm Reduction (THR):
Alternative options like electronic cigarettes provide continued smoking without the harm of traditional cigarettes.
Other THR options include smokeless tobacco and nicotine patches.
Community Involvement in Harm Reduction:
Nurses participate in programs such as:
Promoting helmet use for bicycles.
Distributing condoms to control STI spread.
Promoting clean needle exchange programs to reduce blood-borne illnesses among IV drug users (IVD).
Safety Net Role of Harm Reduction:
Harm reduction models serve as a safety net, mitigating potential harm for individuals.
Nurses ensure access to clean supplies, safe disposal for syringes, and supportive services for physical and mental safety for both individuals and the public.
Response to Opioid Crisis:
Extending harm reduction initiatives to promote safe consumption for opioid users.
Providing medically safe alternatives to street drugs due to concerns around fentanyl overdose deaths in Canada.
Safe Injection Sites:
Vancouver’s “Insite” is North America’s first safe injection facility.
Opened in 2003 in Vancouver’s Eastside.
Operates from a harm reduction model.
High IVD use and mortality rates in the area prior to opening.
Prior Conditions:
Users self-injected in alleys, risking theft, violence, arrest, or overdose.
After Insite’s opening, fatal overdose rate decreased by 35% in the area, compared to 9.3% decrease elsewhere in the city (Marshall et al., 2011).
Facility Features:
Comprised of 12 booths for injection.
Employed nurses, counsellors, and support staff.
Clients received clean needles and supplies, could exchange dirty needles, were monitored for overdoses, and received emergency care when needed.
Provided access to health care, addiction treatment, mental health counselling, and social support.
Benefits of Insite:
Expanded beyond a needle exchange program to comprehensive health services.
Saved taxpayers $1.9 million annually in HIV and overdose-related health care costs (Pinkerton, 2011).
Nursing Role:
Nurses are instrumental in providing harm reduction services.
Advocated against the site's potential closure when challenged by the government.
Supreme Court ruled against closure, emphasizing constitutional rights of marginalized citizens (Lynkowski, 2011).
Advocacy Efforts:
Canadian Nurses Association (CNA) actively advocated for harm reduction, engaging with health ministers and promoting policies.
Political landscape became more supportive after the 2015 federal election, easing barriers for new facilities across Canada (Kerr et al., 2017).
Challenges Faced:
Implementation issues persist due to bureaucratic requirements and NIMBYism (not in-my-backyard attitudes).
Advocating with diverse community stakeholders is essential for effective policy influence (Bardwell et al., 2017).
Nursing Activism & Social Justice:
Nurses engage in advocacy to educate about the foundational principles and benefits of harm reduction.
Address root causes: poverty, inequity, and social injustice.
Advocates for access to services for marginalized groups (homeless, substance users, etc.) and promotes community safety and health equity.
Nurses provide care for individuals across their lifespan from conception to death.
Settings range from acute-care institutions to community-based environments and homes.
The ultimate goal is to help individuals reach and maintain their maximum level of health and wellness.
Many patients face health issues that could have been prevented with early intervention or prevention strategies.
Nurses recognize that “an ounce of prevention is worth a pound of cure.”
Close interactions with patients help nurses understand the challenges posed by illness and injury for individuals and their families and communities.
Nurses see the chain of events leading to life-threatening or life-altering outcomes.
Their passion for health promotion stems from awareness of real-life impacts on people.
An example includes the Canadian Research 8.1, which emphasizes nursing research and its role in promoting health.
Nursing has a long history of social activism and action:
Leaders like Florence Nightingale shaped the profession as a social movement for reform.
Lillian Wald initiated public health reforms, such as child labour changes and establishing the Children’s Bureau.
Lavinia Dock fought for women's voting rights.
Margaret Sanger coined the term “birth control” and was jailed for advocating for it.
Despite this history, nursing activism has diminished, focusing more on patient advocacy rather than broader social issues.
Social justice becomes a critical component of advocacy in public health and community nursing.
There is a shift from hospital-based practice to community settings, allowing for more focus on health promotion and advocacy.
Ignoring political realities in health, especially health inequities, normalizes the status quo.
Health professionals must engage in objective debate and cannot remain silent about injustices, which is a political act.
According to the CNA (2000), main determinants of health and illness are social, political, and economic.
Nursing is inherently political as it involves addressing the social context of health issues.
Nurses should empower clients, patients, and communities, potentially developing into political activists.
Rhetorical questions encourage nurses to think about effective advocacy:
Should the focus be on helping people adapt to poverty or on helping them change their unhealthy environments?
Engaging in upstream approaches can lead to meaningful change by addressing the social determinants of health.
Structural changes from policy modifications are necessary to address the underlying causes of health issues.
Nursing actions may include lobbying for resources to support community health and wellness initiatives, such as safe play areas for children.
In Jason’s story, applying community development principles could help mobilize support for safe play spaces in his neighborhood.
Health Promotion Planning and Programming
Must include multiple levels where nurses can take action.
Individual-level interventions typically consist of:
Key components such as nutrition and lifestyle teaching.
Limitations of individual-level interventions:
These interventions are not sufficient if the goal is to create better health for whole populations.
Social determinants of health must be integral to all interventions for lasting change.
Primary Prevention Challenges:
Teaching about the hazards of smoking and implementing stop-smoking programs are insufficient.
For every adult who quits, there is often a child who begins smoking.
Need for Root Cause Addressing:
We often resort to band-aid solutions and a downstream approach.
Effective health improvement requires large-scale structural, systemic, and societal changes.
Urgency for Change:
These changes are especially critical for improving the health of Indigenous populations and confronting systemic and societal racism.
Importance of Political Will:
Requires political intervention for necessary reforms, as emphasized in international health promotion charters.
Nursing’s Scope of Practice:
Includes advocacy and a need for social action and activism at a broader level, akin to the work of Lillian Wald and Margaret Sanger.
Nurses must practice from a position of cultural safety and uphold social justice principles.
Consequences of Inaction:
Remaining silent or unwilling to act perpetuates the status quo.
Contributes to marginalizing practices that harm individuals and communities.
Ethical Considerations:
Nurses must reflect on whether to continue providing ineffective band-aids for individuals facing systemic barriers to health.
Key Considerations:
The focus should be on addressing root causes of health issues rather than temporary fixes.
Long-term solutions require deep engagement with social determinants and systemic injustices
chapter 15
Introduction
Exponential growth in the use of internet-based information and communication technologies (ICTs) by health professionals and the public.
ICT: A variety of computer-based technology systems that support:
Gathering
Analyzing
Archiving
Retrieving
Processing
Transmitting information and communication.
Empowerment through ICTs:
Increases control over health
Allows access to health information
Provides social support
Facilitates behaviour change
Supports community mobilization
Primary health care nursing service delivery can be improved through innovative, interactive e-health interventions tailored to individual needs.
E-health definition (Hebda and Czar, 2013):
A wide range of health care activities involving the electronic transfer of health-related information on the Internet.
Telehealth definition (Hebda & Czar, 2013):
Use of telecommunications technologies and electronic information to exchange health care information and provide long distance clinical health care to clients.
Referred to as digital health:
Inclusion of ICTs into patient or client care to assist individuals in tracking, managing, and improving their health (Topol, 2013).
Rapid expansion of digital health applications in the last decade:
Report: 72% of family physicians refer patients to websites for health care and lifestyle information (Canada Health Infoway, 2015).
Integration of ICTs into nursing was previously a specific strategy (CNA, 2006), now is an essential component of nursing practice in all settings, including community health nursing.
Nursing informatics defined as:
Use of information and computer technology to support all aspects of nursing practice, including:
Direct delivery of care
Administration
Research
Education (Hebda & Czar, 2013)
Using the concept of digitally connected health:
ICTs empower nurses and assist the Canadian health care system to meet patient needs and achieve a primary health care focus (Topol, 2013).
Nursing informatics as a means to promote health for people, families, and communities worldwide (CNA & CNIA, 2017, p. 1).
Support for Community Health Nurses (CHNs) includes:
Promoting health
Preventing illness
Enabling consultations
Educating clients and families
Providing service
Providing therapy
Supporting and managing chronic disease.
CHNs are expected to meet the Canadian Community Health Nursing standards of practice (CHNC, 2019 revised), which include specific standards related to nursing informatics.
In this chapter, you will learn about:
CHN competencies related to nursing informatics
Current research on digital health
Innovations in technology for health promotion, disease prevention, chronic disease management, and health-related communication.
ICTs that support professional development and knowledge exchange in community nursing
NURSING INFORMATICS COMPETENCIES
Canada Health Infoway:
An organization focused on the transformation of health care in Canada through effective use of information technology (IT).
Federally supported organization that facilitates the implementation of health information systems necessary for managing Canadians’ health information.
Provides support for various stakeholders, including:
Clients
Health care providers (HCPs)
Health care managers
Organizations
Support for Nursing Informatics:
Canada Health Infoway aided the Canadian Association of Schools of Nursing (CASN) in identifying expected ICT competencies for nursing graduates.
Provided strategies and a toolkit to facilitate teaching these competencies.
Overarching Competency:
The use of ICTs to support information synthesis in accordance with professional and regulatory standards in the delivery of patient or client care.
Entry-to-Practice Competencies of ICT are highlighted in three areas:
Uses relevant information and knowledge to support evidence-informed patient/client care.
Uses ICTs in compliance with professional and regulatory standards as well as workplace policies.
Applies ICTs effectively in the delivery of patient/client care.
These informatics competencies build on foundational aspects of existing registered nursing professional standards, including CASN (2014) public health competencies:
Applies health literacy when working with clients.
Appropriately uses social media, community resources, and social marketing techniques to disseminate health information.
Documents population health nursing activities.
Uses effective communication techniques to influence decision makers.
Importance of Nursing Informatics:
National-level nursing informatics competencies are being developed in various countries by prestigious agencies, such as the Centre for Disease Control and Prevention in the United States.
Public Health Informatics Definition:
Defined as “the systematic application of information and computer sciences and technology to public health practice, research, and learning” (Hebda & Czar, 2013).
Emphasizes a population health perspective on disease surveillance and management.
Canadian Community Health Nursing Standards of Practice:
Based on primary health care principles; includes appropriate use of technology and resources.
Standard 7: Professional Responsibility and Accountability
CHNs expected to identify a variety of information sources and determine which are reliable to support nursing practice (CHNC, 2019, revised).
The Canadian Nursing Informatics Association and Canadian Nurses Association have recommended internet and computer competencies for nursing graduates (CNA & CNIA, 2017).
The need for:
Strong ties between nursing informatics and evidence-based practice.
Increased informatics skills for educators, clinicians, and students.
Clear coverage of informatics in curricula.
Stronger human, material, and financial infrastructure for ICT in health care settings.
Strengthened partnerships with the private sector.
Rapid Growth in Internet Use:
Nearly all Canadians under the age of 45 report daily use (Statistics Canada, 2017).
Increasing access to health information.
Internet Use Survey (2009):
69.9% of individuals searched for medical or health information at home using the internet (Statistics Canada, 2009).
Statistics Canada Report (2013):
97% of Canadian households had internet connections.
98% of high-income households had high-speed internet connections, while only 58% of low-income households reported the same.
This disparity affects effective internet use (Statistics Canada, 2013).
Pew Research Internet Survey (2011):
A prevailing disparity in internet access in the United States.
By 2017, approximately 75% of American adults had broadband internet.
Older adults, racial minorities, rural residents, and individuals with lower education/income levels were less likely to report internet access (PEW Research Center, 2017).
Role of Librarians:
73% of adults stated librarians help find health information.
42% used library facilities for online health information.
Women and individuals with higher education levels are more likely to use libraries.
Rooks et al. (2012):
People of color and ethnic minorities are less likely than Caucasians to seek information online or to engage in discussions with physicians using online resources.
Accessing Health Services:
Frequent internet users tended to access health services more often than those who do not seek digital health information (Suziedelyte, 2012).
Impact of Treatment on Internet Use:
Half of individuals prescribed contraceptive medications sought additional information online, indicating the need for increased health teaching (Russo et al., 2013).
Online Health Maintenance:
Canadians are increasingly using online sources for personal health management.
2009: Only 1.4% of Canadian internet users purchased pharmaceuticals online.
2012: 6% purchased pharmaceuticals online; 15% purchased health or beauty products (Statistics Canada, 2013b).
Health-Related Decisions:
Many individuals use online sources to inform health-related decisions and lifestyle behaviours; this is the third most frequent use of internet information (Ramsey et al., Corsini, Peters, & Eckert, 2017).
Digital Health Information Usage:
Adults with disabilities or chronic diseases are generally less likely to use the internet overall.
However, those who do go online search for health information more frequently than those without chronic conditions (Fox, 2007).
Anxiety and Internet Use:
Individuals with high health anxiety searched online more frequently and for longer durations, which increased their anxiety levels (Muse et al., 2012).
Improvement in Patient-Physician Relationships:
A systematic review found seeking online information and discussing it with a physician could enhance patient-physician relationships (Tan & Goonawardene, 2017).
In 2012, over 72% of people discussed online resources with their physicians, resulting in a more positive relationship (AlGhamdi & Moussa, 2012).
Health Status Perception:
Individuals perceiving their health as poor or who experience significant anxiety related to their health status use the internet more frequently, independent of their relationship with physicians (Xiao et al., 2014).
Manafo and Wong (2012): Accessibility and availability of online nutrition information can enable some older adults, while overwhelming others.
Health Literacy: Generally defined as an individual's ability to obtain and use health information for making decisions about health behaviors and care.
Related to health status, health care service use, and self-care behaviors.
Influenced by factors such as age, race, ethnicity, and socioeconomic status (Ownby et al., 2014), contributing to health inequities.
Xie (2011): Health literacy courses can increase older adults' confidence in accessed information.
Chaudhuri et al. (2013): Older adults prefer sources where they can discuss information rather than relying on the internet, newspapers, or television.
Health professionals are preferred sources of information.
The Canada Health Infoway is implementing a Pan-Canadian electronic health record (EHR), advocating for patient access to their EHR data.
Despite over 80% of Canadians wanting online access to their EHR info, only 4% report having it (Zelmer & Hagens, 2014).
Risling et al. (2017): Patient portals providing online personal health information significantly influence patient empowerment and engagement.
Personal empowerment involves involvement and responsibility, enhanced by online resources (Lemire et al., 2008).
Three aspects identified by internet users:
Agreement with expert advice
Self-reliance through individual choice
Social inclusion through collective support.
Determinants for using online health information:
Perceived usefulness
Concern for personal health
Specific health issues
Importance of physicians' and health care professionals' opinions
Trust in online information (Lemire et al., 2008).
Khechine et al. (2008): Individuals with long-term illnesses more likely to access scientific websites for treatments and follow-up.
About 25% of respondents frequently used online discussion forums for information.
Hoffman-Goetz et al. (2009): 91% of advice in forums congruent with best practice guidelines.
Cole et al. (2016): Quality assessment of advice in discussion forums indicated only a small amount was of poor quality.
Recent findings show health-literate clients rely on online information to prepare for medical appointments, enhancing health-seeking behaviors (Ramsey et al., 2017).
Less health-literate clients and those from rural areas may lack confidence in accessing credible resources or discussing them with HCPs (Dean et al., 2017).
Women more likely than men to use the internet for health information (Manierre, 2015).
Nurses' Role: Important in health education when working with internet users, noting that online health information is just one method of communication.
Some clients may depend on non-online sources like written materials and professional explanations.
Careful assessment of client needs is essential.
Internet Access Issues:
Many populations use the internet for health information, but access is not equitable.
Digital Divide (Tapscott, 1998): Refers to the distinction between internet users and non-users resulting in information "haves" and "have-nots".
Over the years, the digital divide has changed:
Youth were early adopters of the internet, but older adults are now the fastest growing group of users.
69% of adults over age 65 use the internet; over half of them search for health-related information (McMaster Health Forum, 2014).
The percentage of older adults using the internet continues to grow but is lower for those over 75 (around 21%, Statistics Canada, 2010).
Older persons in the lowest income brackets contribute significantly to the persistent digital divide:
In 2012, only 28% of Canadians aged 65 and over with the lowest incomes used the internet compared to 95% of those aged 16-24 in similar income brackets (Statistics Canada, 2013a).
Main limitations to internet use include:
Lack of computers and internet access at home (McMaster Health Forum, 2014; Statistics Canada, 2013a).
Significant limitations for individuals with low income, limited education, living on First Nation reserves, in rural areas, and those in minority ethnic groups or recent immigrants (Statistics Canada, 2013a).
Older adults may have limitations in accessing internet information and concerns about the credibility of the information accessed (Chaudhuri et al., 2013; McMaster Health Forum, 2014).
Despite challenges, people are motivated to use online resources if they:
Meet their needs.
Are appropriate for their life stage and age.
Allow for interaction with others with similar interests.
Provide opportunities for self-paced learning or possible interventions (Ammerlaan et al., 2017).
Low-income communities, older adults, ethnic groups, and disadvantaged populations can benefit from community-based internet access to foster healthier neighbourhoods (Chaudhuri et al., 2013; Lober & Flowers, 2011).
However, these groups in Canada may need significant support and encouragement from health care providers (HCPs) to utilize online resources (McMaster Health Forum, 2014).
The internet can also be a poor source of health information:
Notably for populations like the Chinese immigrant community in Vancouver and Seattle (Woodall et al., 2009).
Nurses should not assume that all clients can or will access the internet for health information and must address accessibility issues for vulnerable populations.
The circulation of "fake" health information is a growing problem:
Often stems from websites promoting specific treatments or approaches based on faulty or questionable research.
Examples include misinformation around immunization and its relationship to conditions like autism, often promoted by public figures (Specter, 2013).
A role for Community Health Nurses (CHNs) is to utilize strong evidence in health decisions:
Recognize that laypeople may struggle to identify questionable websites.
Youth: Early tech adopters with potential to empower their health decision-making, though they face distinct access issues:
Valaitis (2005) notes factors like privacy, gatekeeping, timeliness, and functionality are vital when designing resources for youth.
Youth often congregate on websites or chat rooms that may pose risks to their well-being.
They may not understand the privacy risks involved in divulging personal information online.
Usually consult peers instead of knowledgeable adults about website credibility.
Access for Populations who are Differently Abled
Community Health Nurses (CHNs) frequently work with populations living with disabilities.
Disabilities can take various forms and may be linked to both acute and chronic situations.
Individuals who are differently abled can benefit significantly from using Information and Communication Technologies (ICTs).
ICTs can help to:
Reduce social isolation
Connect with others who have similar experiences
Enhance communication
Improve access to health information (McMaster Health Forum, 2014).
Web Accessibility Standards
The World Wide Web Consortium (W3C) is an international body overseeing the standardization and operation of the web.
In 1997, the W3C initiated the Web Accessibility Initiative to ensure equitable access to information for all, including individuals with disabilities (W3C, 2017a).
Accessibility standards were formulated for web content designers and developers.
The Web Content Accessibility Guidelines (WCAG) 2.0 provides a framework for evaluating accessibility factors in online resources (W3C, 2017b).
Tutorials are available to assist designers in making their sites accessible for individuals with disabilities (W3C, 2017c).
Defining Accessibility
Accessible materials are defined as those usable by a wide range of individuals with disabilities, including:
Blindness and low vision
Deafness and hearing loss
Learning difficulties
Cognitive limitations
Limited movement
Speech difficulties
Photosensitivity
Other combinations of these conditions (W3C, 2017c).
Standards are categorized into various priority levels.
Disability advocates urge that websites should, at the very least, achieve the Priority Level One standard for accessibility.
Principles of Accessibility:
Related to:
Perceivability: Users should be able to perceive the content offered.
Operability: Users must be able to navigate and operate the interface effectively.
Understandability: Content should be clear and easily understood by users.
Robustness: Content must be compatible with various technologies, including assistive technologies.
Guideline One Design Standards:
Design standards are relatively simple to meet.
Webpage Images:
Must include clear text descriptions for accessibility.
HTML Code:
Should incorporate "alt tags" (alternative text tags).
Provides a text description when a user rolls over an image.
Useful for users when browser preferences are set for "text only".
Beneficial for individuals who are visually impaired.
Screen Readers:
Convert screen text to speech.
Can read alt tags to inform users about the images displayed.
Contrast:
Use of contrasting background and text colours is essential.
Ensures web documents are navigable.
Implementation of Guidelines:
Many government health resources now integrate these accessibility guidelines.
However, health information websites often receive failing grades regarding accessibility and usability.
Goldberg et al. (2011): Highlight the necessity to address accessibility issues early in the development process.
Usability is defined by the user experience of the website.
Public Engagement with E-Health:
Hardiker and Grant (2011) identified factors affecting public engagement:
Improved access to information.
Tailored services are needed for ease of use.
Research Gaps:
Burns, Jones, Inverson, and Caputi (2013):
Noted the lack of current research on the usability of websites for individuals with visual and auditory disabilities.
Limited access to translation devices is a significant issue.
Assistive Technologies:
Various software and hardware help differently abled populations:
Screen Readers: Assist visually impaired users.
Screen Magnifiers: Increase the visibility of screen content.
Braille Displays: Translate text for Braille reading.
Voice Recognition Technologies: Convert spoken words into text.
Data Extraction Tools: Filter overly busy webpage content.
OCR Software: Converts printed material into electronic text for accessibility.
Portable Note-taking Devices: Useful for individuals with speech communication disorders.
Ergonomic Adapters and Dictation Programs: Assist users with mobility challenges.
Operating System Adjustments:
Most systems allow simple enhancements for accessibility.
Users can explore the "Accessibility Options" folder in their computer's control panel to adjust settings for hearing, vision, and mobility.
Quality of Digital Health Information:
Recent emphasis shifted from educating about health issues to accessing health information.
Empowerment through access to good-quality health information.
Increased public access introduces risks and opportunities.
The quality of online health information is highly variable.
Public challenges: determining the quality and credibility of health information.
Types of Digital Health Information:
Health promotion information
Screening tests
Personal accounts of illness
Patient testimonials about treatment effectiveness
Patient opinions or experiences
Product advertisements
Treatment providers
Discussion and support groups
Peer-reviewed articles and decision-making aids.
Role of Community Health Nurses (CHNs):
Assist clients to become knowledgeable consumers of online health information.
Support client skills and promote the use of patient portals for easier access.
Identify clients needing assistance:
Limited computer skills
Limited computer access
Poor health literacy
Need for assistive devices.
Individuals with lower educational levels or from certain ethnic groups may be less likely to access these resources.
Individuals in later stages of illness may require more assistance.
Technical Support:
Providing easily-accessible technical support increases client usage of online resources.
Client Concerns:
Many clients using patient portals express concerns about information security and privacy.
Nurses can reassure clients regarding privacy protection.
Assistance is available for clients to use the internet safely and protect their information security.
Patient Portals:
Standard portal formats can enhance ease of navigation and facilitate client usage (Kruse et al., 2015).
Provision of recommended resources within portals may include a health library that explains:
Terminology
Test procedures
Lab results
Medications
Treatments
Nurses can play a role in the design of patient portals to improve resource understanding for clients.
Evaluating Online Resources:
When clients seek online resources independently, nurses can help assess the quality of these resources (Dickerson, 2006).
Use of reputable websites like Health on the Net can guide clients on evaluating health information quality.
Accessing Local Resources:
Nurses can promote local resources available in clients’ home communities (Dickerson, 2006).
Credibility of Internet Health Information:
Users continue to access various internet health resources despite concerns about credibility.
Resources accessed include:
Health promotion materials
Scientific and medical information
Patient experiences and testimonials (Kivits, 2009; Ramsey et al., 2017).
Many users claim to use criteria such as
Source credibility
Language
Transparency
However, these criteria are often disregarded during searches.
User Behavior:
Users frequently rely on search engine results or personal experience to assess information usefulness (Eysenbach, 2007).
Evaluation often based on content correspondence from other websites (Kivits, 2009).
Users typically develop practical knowledge based on their experiences (Kivits, 2009).
Search Techniques:
Poor techniques noted, reliance on initial links from search results is common.
Kitchens, Harle, and Li (2014) found users often do not refine searches effectively.
Internet Familiarity vs. Credibility:
Increased comfort with the internet does not equate to the ability to access credible health information.
Study Insights:
A study on English-speaking Caribbean immigrant women revealed high internet use with poor knowledge of website domains (.edu, .gov, .com, .net) (Changrani & Gany, 2005).
Users primarily clicked on first search results without refining or repeating
Tools Available for Rating Digital Health Information
Quality Rating Tools: Numerous tools exist for consumers and health care professionals (HCPs) to evaluate the quality of digital health information.
Evaluation Dimensions: Several dimensions of internet resources to assess:
Content: The substance and relevance of the information provided.
Journalistic Value: The credibility and reliability of the information source.
Targeted Audience: The intended audience for the information.
Website Design: User interface and navigation effectiveness.
Readability: The ease of understanding the content by the average reader.
Usability: Overall user experience in accessing and interacting with the site.
Ethical Issues of Privacy: Consideration of user data protection and confidentiality.
Impact of Web 2.0 Technologies: The emergence of technologies such as collaborative, adaptive, and interactive sites has influenced how these dimensions are evaluated (Burns et al., 2013).
Value Determination Difficulties: Consumers often find it challenging to determine the value of ratings on health information websites.
Providing Clear Criteria: Offering clients clear criteria for assessing the credibility of online information is crucial for effective evaluation.
HON Code Usage: Employing the HON code (www.healthonnet.org) helps in critiquing and assessing online information.
This assists clients in understanding and applying the criteria effectively.
HON Website Features: The HON website offers a search engine to simplify finding HON-certified websites based on user-entered search terms.
US National Library of Medicine: Provides an online tutorial designed for laypersons to determine the quality and usefulness of online health information (https://www.nlm.nih.gov).
Encouragement from CHNs: Community Health Nurses (CHNs) should encourage and support clients in accessing and utilizing these resources.
Assessment Questions: Table 15.2 contains questions clients can use to evaluate digital health information, empowering them to engage more confidently with online resources.
WRAPIN Service: The HON Foundation offers the WRAPIN service (www.wrapin.org) where consumers can submit URLs to check site accreditation and trustworthiness.
Multilingual Support: The service is available in multiple languages, broadening accessibility.
HON Code Toolbar: Clients can download the HON code toolbar to search specifically for HON-approved sites.
Usability of Health Information Websites:
Usability might involve more than just accuracy of the information.
Evaluative criteria focus on usability for consumers, including:
Navigation
Design
Criteria for Evaluating Health Information Websites (Mitretek Systems Health Summit Working Group, 2017):
Credibility
Content
Disclosures
Links
Design
Interactivity
Caveats
These criteria relate to information presentation and ease of use.
Credibility of Information:
Essential for determining the usefulness of the website.
Based on:
Expertise of the authors.
Sponsoring agency credibility.
Currency of the information.
Relevance to the user’s health issue.
Perspective of Health Professionals:
Importance of accuracy and supporting evidence.
Information must be clear and targeted to the intended user.
Sources should be identifiable and understandable.
Users appreciate interactivity, but privacy and security must be clear.
Ease of Navigation:
Vital for user experience.
Navigation links should:
Be clear and easily used.
Indicate links to outside sites clearly.
Offer a way to return to the original site easily.
Content maps and search options facilitate user persistence.
Readability of Text: An important design aspect of every webpage.
Readability: Measure of how easily and comfortably text can be read.
People with lower reading skills also utilize the internet.
Websites for Laypersons:
Reading levels should target approximately a Grade 9 level (Canadian Public Health Association [CPHA], 2018).
Experts recommend that the majority of the population prefers written materials three grades below their last attended school level (Bastable, 2013).
This recommended level may still be higher than the general population's actual reading comprehension, estimated at an average of Grade 5–6 (Bastable, 2013).
Canadian Educational Statistics:
89% of Canadians aged 25 to 64 have completed high school.
65% have completed post-secondary education (Statistics Canada, 2014).
Despite these statistics, 42% of the working-age population scored below functional level in prose literacy.
43% scored below functional level in document literacy (OECD & Statistics Canada, 2011).
42% of Canadian adults aged 16-65 have low literacy skills, with 55% of that group having inadequate health literacy skills.
88% of individuals over 65 fall into the low literacy category.
Website Reading Levels:
Many websites contain texts at much higher reading levels than can be comprehended by a large portion of the general population.
Ache and Wallace (2009): Internet-based client education materials generally written at Grade 7 to 12 levels, with an average of Grade 11.
Lam, Roter, and Cohen (2013): 86% of adolescent websites failed to meet readability standards of less than Grade 8.
Readability Assessment Tools:
Health professionals can use the SMOG (Simple Measure of Gobbledygook) Readability Test (McLaughlin, 1969) to evaluate written or internet text.
SMOG reading levels correlate well with other readability assessment tools (Bastable, 2013; Beaunoyer et al., 2017).
Improving Text Readability:
Readability tests assess word and sentence length; reduce complexity by using simple words and shorter sentences.
CPHA published the Directory of Plain Language Health Information to assist health educators in creating clear materials.
CPHA offers a plain language service for assessment and clarification of health resources (CPHA, 2018).
Website Navigation and Usability:
Key factors in evaluating online health information include ease of navigation and accessibility of webpages (Goldberg et al., 2011).
Utilizing internal links is beneficial to enhance user access.
External links should be evaluated for relevance and ease of returning to the original site.
Visual and Interactive Elements:
Use of graphics to illustrate concepts improves usability.
Advertising and pop-ups may hinder the user experience.
A visually appealing design and interactive features (e.g., BMI calculators, calorie counters) enrich user engagement (Lustria et al., 2009).
Videos enhance user satisfaction and information recall (Bol et al.,
Ease of usage enhances a user’s ability to read and use information contained on a website. Clients can also be referred to government-sponsored health infor mation websites that have high credibility and accuracy of information.
Targeting Specific Users of Digital Health Information
Online health information should be designed for specific users.
A combination of health messaging with individual-level participant information allows for better targeting.
Targeting involves the development of online resources that enable:
Personal and direct content presentation.
Focus on preferences, needs, and current health behaviours or intentions leading to positive outcomes (Lustria et al., 2009).
Concept is derived from advertising principles related to market segmentation.
Research with immigrant populations indicates the necessity for health information that helps in:
Making informed decisions about health.
Understanding vulnerabilities to health risks (Kreps & Sparks, 2008).
Needs includes:
Access to culturally relevant, accurate, and timely health information.
Information should align with the cultural beliefs, values, and attitudes of the targeted group.
Health education messages should be:
Pre-tested with representatives of the target group for cultural sensitivity.
Offered in multiple messaging strategies for message reinforcement.
Preferences for interactive communication:
Users prefer the ability to ask questions and interact with knowledgeable respondents.
Website design challenges for older adults:
Scrolling through websites can be difficult.
Websites presenting one paragraph per webpage are more accessible.
Example:
The U.S. National Institute on Aging provides a website with features to:
Enlarge text.
Activate a talking function for better accessibility.
Provides links to credible websites for older adults to assess the value of the health information accessed.
Websites with these features are expected to be more beneficial for older adults.
Tailoring Digital Health Interventions
Integration of Features
Enhancing interactivity in digital health interventions improves learning (Goldberg et al., 2011; Hardiker & Grant, 2011).
Interactivity defined as active participation of users in technology use and information exchange (e.g., chat rooms, calorie calculators, links).
Social Cognitive Theory
Computer programs using this theory have shown positive results in promoting behavior change for managing weight and physical activity.
Behavioural Economics
Combining this concept with interactive digital health interventions leads to unique health promotions, such as the Carrot Rewards application.
This app utilizes loyalty programs: users earn points for activities like:
Movie purchases
Grocery store purchases
Gas purchases
Travel
Users earn points for:
Downloading the app
Referring friends
Completing short educational health quizzes (micro-learning) to increase health knowledge and promote healthy behaviors (Mitchell et al., 2017).
Assumptions and Resource Access
Programs assume participants have access to resources and may not consider social determinants of health contributing to obesity.
Content should reflect participants' needs: focus on low-cost, healthy, and easily accessible foods.
Personalized Responses
Programs that generate personalized responses can:
Increase positive attitudes
Improve learning about health issues
Achieve positive health outcomes (Suggs & McIntyre, 2009).
Important to ensure user anonymity in these programs (Hardiker & Grant, 2011).
Tailored Messages
Tailored messages:
Include the user’s name
Address individual health needs directly.
Tailoring differs from targeting (which focuses on groups); it creates individualized intervention materials.
Tailored messages are often "pushed" to users, while targeted messages rely on users to "pull" information from available resources.
Research and Statistics
Only 13 out of 497 English-language online health resources were tailored messages (Suggs & McIntyre, 2009).
A comparison of tailored vs. targeted interventions showed targeted interventions are preferred and more cost-effective (Kerr et al., Savik, Monsen, & Lusk, 2007).
Tailoring based on individual characteristics (e.g., age, gender, readiness) typically outperforms static health information (Bennett & Glasgow, 2009).
Technology to Support Health Promotion, Disease Prevention, and Chronic Disease Management
Primordial Prevention
Growth of ICTs: Increased use of Information and Communication Technologies (ICTs) to support e-health intervention.
Attributed to:
Increased internet use by the public
Low cost of delivery
Public willingness to actively manage their health
E-health interventions are effective in:
Self-education
Self-enhancement
Current focus on healthy lifestyles involves strategies such as:
Addressing nutrition and exercise
Avoiding harmful situations
Advocating for healthy policies in the community
Using organic foodstuffs
Incorporating precautions (e.g., child car seats)
Technology's Role:
Wearable fitness devices
Websites supporting healthy lifestyles
Primary Prevention
Aimed at reducing the incidence of disease by:
Reducing the impact of specific risk factors
Interrupting causal factors before physiological manifestations of illness
Digital health solutions:
Useful for improving lifestyle choices and avoiding risky situations
Secondary Prevention
Involves interruption of the chain of causality or reduction of disease prevalence.
Utilization of online resources for:
Screening conditions
Exploring symptoms via online sources like Health Canada
Successful interventions in areas such as:
Weight management
Cancer care
Gambling addiction
Smoking cessation
Asthma care
Hypertension management
Tailored messages for online screening interventions have been effective in:
Mental health
Sexually transmitted infections (e.g., chlamydia, gonorrhea)
Cervical cancer screening in adolescents
HIV/AIDS prevention
Successful internet interventions have also facilitated:
Online counseling for individuals in remote areas
Anonymity and special interest groups
Impact of Interventions
Systematic reviews indicated significant positive outcomes in:
Diet
Physical activity
Medication management (e.g., breast cancer, diabetes)
Research shows no harm from health informatics interventions
The internet as a platform for health interventions shows potential for broad population dissemination
Effective weight-loss interventions are structured, tailored, and regular in follow-up
Conclusion
Technological interventions are pivotal in improving public health through ICTs in various prevention strategies.
Tertiary Prevention: Focused on reducing the persistence of disease.
Quaternary Prevention: Aims to reduce the impact of over-medicalization of a person’s condition.
Online Resources: Address both tertiary and quaternary prevention effectively.
Web 2.0 Technologies: Includes platforms such as YouTube, Twitter, Facebook, Instagram, and MySpace.
Gained popularity, especially among youth and those experiencing stigmatization.
Social Media Use:
67% of Canadians using the internet in 2012 visited social networking sites, up from 58% in 2010 (Statistics Canada, 2013a).
Research on health promotion via these platforms is increasing (Antheunis et al., 2013; Griffiths et al., 2012; Househ et al., 2014).
User-Generated Content: Social media allows creation and exchange of content by users.
Provides opportunities for clients to access health information, explore care options, and share health experiences.
Health Topics: Social media facilitates interactions around various topics related to patient education, health promotion, public relations, and crisis communication.
Social and Participatory Nature: Web 2.0 emphasizes user empowerment and inclusion, enhancing health promotion and prevention levels.
Facebook as a Health Promotion Tool: A conversation regarding sexual health showed:
93% of the content was user-generated.
576 users interacted over a five-month period.
Participation ceased when advertisements discontinued (Syred et al., 2014).
YouTube's Role: A valuable source of health information.
Example: A search for “human papillomavirus” revealed approximately 160,000 video clips in April 2014.
In 2011, Canadians watched more online videos than any other population globally, with a 170% increase in viewership (CIRA, 2013).
Interactive Digital Health Interventions: Demonstrated higher effectiveness (Burns et al., 2013; Goldberg et al., 2011).
Examples include:
Cost calculators for smoking.
Online support groups for ex-smokers.
Personal story sharing features.
Email follow-ups surrounding quit dates.
Support for New Parents: Rapid growth of online groups offers social support for parents feeling isolated.
Addresses specific needs, e.g. adoption, bereavement.
Online resources used for information and encouragement due to weaker family support (Vennick et al., 2014).
Online Support Groups: Helpful for populations experiencing stigma through their conditions (Royer et al., 2013).
User Preferences: Indicated a desire for social interaction on websites (Goldberg et al., 2011; Lustria et al., 2009).
Emerging Technologies: Research ongoing into the effectiveness of cell phone-based interventions, specifically text messaging, shown to have short-term efficacy in smoking cessation (Whittaker et al., 2009).
Telehealth Technology
Expanding use across Canada.
Provides accessibility to health care and community health services.
Services might not be available to clients otherwise, especially in rural, remote, or disadvantaged populations.
Enables access to health care professionals, health educators, and specialist services typically concentrated in urban areas.
Community Health Nurses (CHNs)
Can utilize telehealth technology to provide:
Assessment services.
Health promotion services.
Educative services to remote populations.
Importance of Telehealth Services
Essential for delivering care to under-served areas.
Increases options available to clients, especially when traditional in-person services are limited.
Examples include support for family caregivers in their homes, helping to empower clients to make decisions regarding their caregivers and the setting of their care.
Recent Developments in Telehealth
Allows health care professionals to:
Assess clients remotely.
Review assessment data effectively.
Diagnose, treat, and counsel clients at a distance (Godwin et al., 2013).
Further enhances the coordination of care and support for ongoing health management (Stern, Valaitis, Weir, & Jadad, 2012).
Population Health and Technology:
Numerous online approaches exist to support population health interventions.
Technology has historically been utilized for community empowerment and capacity building (Korp, 2006; Valaitis, 2005; Valaitis & O’Mara, 2005).
Evaluation of Interactive Website in Calgary:
An interactive website was evaluated for its effectiveness in involving local citizens in policy development related to a smoking bylaw in Calgary (Grierson, van Dijk, Dozios, & Mascher, 2006).
Outcomes of the website included:
Sparked public debate about smoking issues.
Provided crucial information about smoking to citizens.
Suggested messages for communicating with city councillors.
Updated citizens on how the council voted on smoking issues.
Public response was very positive.
The website functioned as an effective community capacity-building tool and mobilization strategy that increased citizen participation in creating local policies for a healthier community.
Findings from Israeli Study:
A similar finding was observed in an Israeli study which engaged stakeholders in evaluating the health impact of a national hazardous industry on nearby land use (Negev, Davidovitch, Garb, & Tal, 2013).
Role of Social Media in Public Health:
Social media has emerged as a powerful vehicle for influencing public health.
Identified usage includes:
Epidemiologic monitoring and surveillance.
Situational awareness during emergency response.
Communication surveillance (Fung, Tsz Ho Tse, & Fu, 2015).
Social media has proven effective in:
Detecting outbreaks.
Promoting disease awareness.
Gauging the impact of health communication.
Social media monitoring supplements existing population-based surveillance systems, providing valuable data for program planning and evaluation.
Canadian Integrated Public Health Information System:
Combines iPHIS—a client health-reporting surveillance system supporting:
Tracking, follow-up, reporting, and management of immunization, communicable disease, and population health surveillance.
Integrates with a laboratory data management system.
Panorama System:
Developed by Canada Health Infoway and includes tools to support:
Outbreak identification.
Vaccine inventory management.
Case management.
Notifications (Mowat & Butler-Jones, 2007).
Panorama data are incorporated into the national EHR.
CANSIM:
The CANSIM (Canadian Socioeconomic Information Management System) tables report social trends affecting the lives of Canadians, accessible through E-STAT, which provides access to Canadian census data.
Available at no cost to students and educators through educational
Electronic Documentation in Community Health Nursing:
Growing use of technology to support electronic documentation systems across Canada, including in community health organizations (Stonham, Heyes, Owen, & Povey, 2012).
Currently focused on acute nursing such as home care nursing.
Potential for Community Health Nurses (CHNs) to link interventions to individuals' health records.
Types of Electronic Documentation Systems:
Electronic Medical Record (EMR):
Typically found in primary health care settings and clinics.
Access is limited to authorized caregivers; reflects previously recorded information in paper systems.
Electronic Patient Record (EPR):
Maintained by health care organizations.
Similar access and content restrictions as EMRs.
Electronic Health Record (EHR):
More comprehensive, includes content from both EPR and EMR.
Typically contains most information from encounters with the health care system (e.g., primary care, pharmacies, labs, diagnostic imaging).
May include immunizations, educative interventions, and health promotion activities embraced by the client.
The client controls access; the record is "owned" by the client but hosted by a jurisdiction (Nagle, 2007).
Current Testing and Utilization:
EHRs provide a longitudinal record of an individual's health history and care, currently being tested in various provinces by Canada Health Infoway.
Community nurses use mobile devices to:
View health records.
Complete documentation.
Order supplies.
Make appointments.
Review medications.
Access evidence for practice.
Creation of EHRs allows CHNs to link their interventions to individual health status, integrating health promotion with client health status.
Documentation Benefits:
Ability to document best practices in care and service with clients (Stonham et al., 2012).
Client expectations identified regarding EMR maintenance (Rutten et al., 2014).
For community-based nurses, access to information at the bedside is a significant advantage (Caligtan et al., 2012; Luo et al., 2012).
Challenges with Mobile Device Use:
Use of mobile devices (cell phones, tablets) at clients' bedsides raises contamination concerns (Albrecht et al., 2013; Unstun & Cihangiroglu, 2012).
Contamination issues include:
Nearly all cell phones owned by health care workers found to be contaminated.
10% contamination with Methicillin-resistant Staphylococcus aureus (MRSA) and 11% with E. coli in intensive care settings.
Tablets can be effectively disinfected using isopropanol wipes (Albrecht et al., 2013).
Technologies Supporting Knowledge Exchange and Professional Development for Community Health Nurses (CHNs)
Information and Communication Technologies (ICTs) significantly enhance the capabilities of CHNs by:
Providing access to supports for professional development.
Enhancing evidence-based decision making.
Types of Technologies:
Online Communities of Practice: These are groups formed by individuals with common interests, values, and problems who collaborate to deepen their knowledge (Wenger, McDermott, & Snyder, 2002).
Portals: Centralized platforms for accessing resources and information.
Repositories: Collections of evidence-based literature in community health.
Networking Needs in Community Health:
Canadian nursing researchers assessed needs for a formal community health network to aid decision makers, researchers, and practitioners.
The emphasis was on facilitating discussions regarding complex community health issues supported by relevant research.
Face-to-face networking was preferred, but a willingness to engage in online networks was noted.
This led to the establishment of CHNET-Works!, an online networking project promoting asynchronous communication and webinars on community health topics (www.chnet-works.ca).
Personal Learning Networks (PLN):
CHNs can utilize social media to create PLNs that facilitate professional development.
Recommendations for new users include starting with one social media tool (e.g., Twitter) and leveraging online resources to set up accounts.
Hashtags (#) can help organize and enhance the exchange of information (
Examples: #cdnhealth, #CHC, #hcsmca, #rnchat).
Online Resources for Nursing Development:
NurseONE/INF-Fusion: Developed by the Canadian Nurses Association to support nurses in managing professional development, connecting with peers, and accessing evidence-based resources (www.nurseone.ca).
Canadian Best Practices Portal: Offered by the Public Health Agency of Canada for knowledge exchange in health promotion and chronic disease prevention (http:// cbpp-pcpe.phac-aspc.gc.ca).
Provides practitioners with online modules for skills enhancement in public health.
Health-Evidence.ca: A search service that provides access to evidence-based materials relevant to CHNs (http://health-evidence.ca).
Effective Public Health Practice Program: Offers links to systematic literature reviews and summaries (www.ephpp.ca).
National Collaborating Centre of Methods and Tools (NCCMT): Provides resources on knowledge translation methods and has developed the Online Health Program Planner, a tool for creating evidence-informed programs (www.nccmt.ca).
Digital health interventions:
Provide extensive and often targeted information.
Expand communication.
Offer new supports to empower individuals, groups, and communities.
Enable a more active role in health management.
Community Health Nurses (CHNs) should:
Incorporate appropriate digital health solutions into their plan of care.
Play a critical leadership role in enabling the public to use online health information resources safely and effectively.
CHNs can:
Ensure accessibility to quality health information for the populations they serve.
Act as advocates to prevent a widening of the digital divide.
The use of digital health solutions supports:
Health promotion.
Disease prevention.
Chronic disease management.
Plays a prominent role in securing a healthier future for all Canadians.
Online resources and social media connectivity provide:
New professional development opportunities for CHNs.
Ready access to communities of practice.
Online learning modules or webinars.
Evidence-based materials to support professional growth and practice excellence.
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