CAPITAL HEALTH REGIONAL LEARNING AND EDUCATIONAL RESOURCES
 
 

TABLE OF CONTENTS

CHAPTER 1 - BACKGROUND AND CONTEXT CHAPTER 2 - FRAMEWORK FOR HEALTH EDUCATION AND PROMOTION CHAPTER 3 - INVENTORY OF HEALTH EDUCATION ACTIVITIES CHAPTER 4 - PARTNERSHIPS IN THE CAPITAL HEALTH REGION CHAPTER 5 - SUMMARY AND CONCLUSIONS APPENDIX 1 - SUMMARY OF RECOMMENDATIONS

APPENDIX 2 - FRAMEWORK FOR HEALTH PROMOTION IN CANADA

APPENDIX 3 - HEALTH-PROMOTING HOSPITALS NETWORK

APPENDIX 4 - PERSONAL INTERVIEWS

APPENDIX 5 - BIBLIOGRAPHY

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CHAPTER 1 - BACKGROUND AND CONTEXT

Overview of Project

The Capital Health Board Education Committee recently developed an education policy that "recognized the importance of education in promoting the health and well-being of people living within the Capital Region". This direction is clearly in line with the overall regional goals and strategies. In the most recent Capital Health Business Plan Update(1), one of the values which underlies the Capital Health core businesses and priorities is: Specific strategies which relate to education and learning opportunities for the general public and health care consumers are identified as critical in the opening remarks in the Business Plan: This program focus is part of two of the three core businesses identified by Capital Health in their business plan: This project supports these themes by identifying the education and learning opportunities within the region, both by Capital Health, and by other key partners and by suggesting areas of focus for the Capital Health board during the next planning cycle.

Project Objectives and Requirements

The objectives that were used for this project allowed the researchers to appropriately focus the proposed inventory of learning and education resources. The objectives include:

Initial Definition of Health Education

The following definition was developed by the project team as the working definition of health education for methodological purposes:
Health education is defined as: any activity undertaken by an organization or agency which enables an individual to cope with, understand and make decisions about issues and circumstances which affect his/her or another family member's health through the provision of information, based on which individuals can make positive changes to affect their health.
Activities which would be covered by this definition could include reading, group discussion, taking a course, attending a seminar or workshop, going to a resource centre, obtaining individual counselling, attending a self-help group or activity and/or any other means of obtaining information verbally, audibly, experientially, electronically or visually.

This definition was augmented by the WHO definition of health promotion at a later stage in the project. The relationship between health promotion, as the over-riding concept, and some of its components, including health education, is shown below:

 

Research Framework for Developing the Inventory

For each organization , there were a number of key components which were considered, including: the type of organization, the primary role of the organization, the focus of the educational activity, the target group served, the method of access to the activity, the medium used, the mechanism for determining effectiveness, the frequency of the activity, the funding sources for the organization, and a listing of other organizations involved in the provision of the health promotion/health education activity.

These factors were used to develop the conceptual framework which became the basis for the interviews and contacts with Capital Health and its partners which in turn formed the basis for the completed inventory of health promotion and education activities.

Methodology

The critical factor was ensuring that the requested audit of educational activities obtained the widest possible coverage of organizations involved in health promotion and health education within the Capital Health region. A preliminary list was developed based on the consultants' knowledge of the organizations involved in health education and health promotion within the Capital Health boundaries. Then, the approach that was taken was one of widening concentric circles. That is, core organizations that have a key role in the Capital Health region were interviewed, and from those interviews, listings of additional organizations involved in health education were developed. Each organization then received a telephone interview. Again, additional organizational involvements in health promotion were solicited. The following graphic illustrates the groups which were sampled to develop the inventory.
 
    The number of telephone interviews conducted was a function of the overall time and budget available. Approximately 125 telephone interviews were completed. In addition, 16 of the larger organizations received a one hour face-to-face interview. Organizations were selected first that were anticipated to have a high degree of involvement in health education and health promotion activities.The key methodology was the development of an electronic data base. This approach has several advantages to a more traditional, paper-based, audit approach:

Structure of this Report

 A companion document to this report, An Inventory of Health Promotion Activities within the Capital Health Region, provides summaries of information from the data base based on a variety of search criteria. The overall data base will also be provided to Capital Health at the completion of this project. The remaining four chapters of this report address the project objectives and requirements outlined earlier. First, a conceptual framework which can be used to address health promotion activities is briefly described. Then, the health education and health promotion activities which are available to residents of the Capital Health region are summarized, based on the findings from an analysis of the organizations included in the inventory. The most effective strategies and supportive conditions for providing health education and health promotion activities are used as a set of criteria for analyzing the activities underway in the Capital Health region. The next chapter presents a brief discussion of partnerships within the Capital Health region. The final chapter provides suggestions for effective action by Capital Health in the field of health education and health promotion with recommendations for the next steps in the development of an action plan.

The report also has five appendices: a summary of recommendations; a more detailed conceptual framework developed by Health Canada; an outline of the European Health Promoting Hospitals Network; a list of the organizations and individuals who received personal interviews; and a bibliography of material consulted in the preparation of this report.
 
 

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CHAPTER 2 - FRAMEWORK FOR HEALTH EDUCATION AND PROMOTION

Role of Health Education and Health Promotion

In researching and conducting interviews for this report it became evident that health education is considered a key strategy in a broader health promotion approach which may include development of healthy public policy. Health education is a critical component in reorienting health services, developing personal skills, strengthening community action, and creating supportive environments. The definition of health education as activities which enable individuals to cope with, understand and make decisions about issues and circumstances which affect their health supports the World Health Organization definition of health promotion:

"... the process of enabling people to increase control over and to improve their health."

In this report, health education and health promotion are terms which are linked, and at times, used interchangeably. The following graphic illustrates the complementary role that such strategies as health education, health promotion and disease and injury prevention play within the overall health system.

    The success of these strategies buffers the need for more intensive health services. Health education provides consumers with the information and skill development to make informed choices about their health. Simple education strategies such as providing health information in plain language help decrease the negative impact of other health determinants such as low literacy. Appendix 2, page 37, presents a fuller discussion of health determinants. By strengthening the role of health education and promotion within the overall health system, particularly primary care, the need for more intense services are reduced by:

Evolution of Health Education and Promotion

Initially, attention in the area of health education and promotion focussed primarily on individual lifestyle choices (diet, exercise and smoking), and on healthy public policy (e.g., seat belt legislation). More recently, because of increased research on the determinants of health, the focus has started to shift, towards the factors which influence health. Recently, the National Forum on Health(2) final report has emphasized the need to broaden the approach to health. This conclusion supports the research from the Canadian Institute for Advanced Research directed by Dr. Fraser Mustard. Results from their studies emphasize the value of early intervention, the negative impact of factors such as poverty and low education and the importance of people having a sense of control in their lives and access to safe, healthy living and working conditions. In support for this type of research the Federal, Provincial and Territorial Advisory Committee on Population Health agreed upon a number of key health determinants and a Population Health Promotion Model. This model is described in Appendix 2, page 41.
 

Increased Effectiveness for Health Education and Promotion

The literature suggests that effective health promotion activities have the following characteristics: The literature highlights the need for the development of evaluation models and outcome indicators for health promotion initiatives. There has been significant work done over the last decade to develop mechanisms for evaluating health promotion activities and identifying outcome indicators. One outstanding issue in measuring the effectiveness of initiatives is the scope of the evaluation. Effectiveness can be measured as any or all of the following examples: It must be kept in mind that the overall effectiveness of health promotion in a region is more than just the sum of the parts. A series of highly effective initiatives may have no discernable impact on the overall health of the population if the impact and coverage of the programs is insignificant relative to the size of the region. The effectiveness factors noted above will be used to assess the findings of the analysis of the inventory of health education and promotion activities in the Capital Health region.

Capital Health's efforts in monitoring the health of the overall population will be critical as overall evaluation mechanisms are put in place to connect results from health promotion activities with benchmarks that lead to overall changes in regional population health.
 
 

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CHAPTER 3 - INVENTORY OF HEALTH EDUCATION ACTIVITIES

Organizations Involved in Health Education and Promotion

The first section of the companion document to this report, An Inventory of Health Promotion Activities within the Capital Health Region, lists the agencies and organizations within the Capital Health Region who were contacted by telephone to determine the health education, promotion and prevention activities which they were undertaking. Similarly, Appendix 4, page 47, identifies the individuals and organizations who were received a face-to-face personal interview. The organizations contacted were selected as a sample of the categories of partners identified in the partnership schematic diagram on page 4. Community organizations and agencies received a total of 45 interviews, 17 of the various branches and organizations within Capital Health were contacted, including several hospitals and other organizational entities. 35 federal, provincial and municipal organizations were contacted, as were 10 professional organizations and 9 provincial level non-government organizations. Other regions were not contacted, but a small sampling of 13 other organizations, including large employers, mass media, businesses, etc., were interviewed.

The Inventory of Health Promotion Activities within the Capital Health Region has some constraints, identified in the introduction to the inventory. However the data base offers an excellent overview and provides a good base for further development. A number of organizations requested that Capital Health restrict distribution of the inventory of activities until the organizations who took part in the telephone interviews have a chance to confirm the accuracy and interpretation of the information.
 

Health Promotion Inventory Findings

Focus of Activity

Most organizations contacted had more than one focus of activity. Thus, more than one response to this question was received from most organizations.
 
Focus of Activity Number of Organizations Reporting
Choosing healthy lifestyles and behaviours 77
General health promotion and protection 73
Understanding health determinants 44
Personal safety and security 39
Dealing with a specific illness, condition or disability 42
Community Support and Development 32
Reproductive and sexual health 30
Use of adaptive techniques and technologies 26
Accessing the health system and services 20
Dealing with another's illness, condition, or disability 20
Consumer rights and responsibilities 16
Understanding health legislation 9
 

The largest single focus of activities was choosing healthy lifestyles and behaviours, followed by general health promotion and protection activities, with nearly half of the contacted organizations or organizational branches being involved in these activities. Only one quarter of the reporting organizations or organizational branches felt they were involved in community support and development.
 

Access to Health Promotion Activities

Access and availability is a significant issue if health promotion activities are to be effective. Organizations contacted had a variety of ways in which individuals became knowledgeable and involved in various health promotion activities.
 
Mechanism for Obtaining Access Number of Organizations Reporting
Consumer-driven (individual seeks out material/activity) 82
Provider-driven - voluntary (provider makes available material/activity or referral as part of service delivery) 46
Provider driven - mandatory (provider requires involvement as a requirement for obtaining services) 32
Joint development of access between consumer and provider 17
Organization/jurisdiction disseminates (to specific groups, target audiences, etc.) 22
 

Given the importance of consumer and community involvement in effective health promotion activities, it is disappointing to see that only 17 organizations report that there is joint development of the access mechanisms. For half of the organizations contacted, the consumer was expected to seek out the organization and activity to obtain access. In the remaining half of the organizations, the provider of the health promotion activity took responsibility for referring or otherwise making available activities and programs to individuals who were already receiving services from the organization. Presumably, individuals who wanted to access resources who were not already receiving services from the organization, would also have to seek out the information on their own. Speaking as researchers, even when organizations were contacted directly, it was not always easy to identify either who to talk to or what health education and promotion activities were sponsored by that organization. "Broadly accessible" is considered to be a critical effectiveness factor, and yet there are significant barriers to consumers in learning about the existence of various health education and promotion activities and projects.

This finding emphasizes the need to develop some easy mechanism for consumers to locate information and other support activities of interest to them. If consumers do not have the knowledge of the availability of resources, they would benefit from the health promotion activity only if they were referred or were already involved with the organization. It would also be difficult to compare similar programs across the region to determine the most convenient time/place or the content best suited to their needs.

Capital Health has already recognized that information and access is a significant need for both seniors and service providers through the establishment of the Senior's Health Line. Monitoring of the usage of the Senior's Health Line indicates that this information line is used heavily by front line practitioners as well as by the seniors themselves. Another major source of information, the Centre for Well Being, is primarily designed for the use of practitioners. Clearly, the overall effectiveness of activities in the Capital Health region could be increased by improving consumer and provider access to information, perhaps through the Capital Health Information line or through publicizing the "Health Line". There is a wealth of information already available. The issue is access to the information at the right time by people who could benefit from the information that already exists within the Capital Health region.

Target Groups

The target group breakdown is more subject to difficulty than any other category. Many organizations specified a large number of target groups, when what was probably meant was that they served the general public. Thus, there is more overlap in the following table than in other sections of this report. Similarly, activities which identify seniors as the target group are usually only available to seniors, but seniors can also benefit from activities that are available to the general public. However, not all target groups can benefit from "general public" programs. For example, individuals for whom English is a second language or who are challenged by low literacy often cannot benefit from general programs or information resources, particularly those which are print based.
 
Target Group Served Number of Organizations Reporting
General public 60
Health providers 36
All health care consumers 24
Parents and their children 31
Persons with Disabilities 25
Youth and young adults 23
Low-income individuals and families 16
Seniors 15
Individuals with English as a Second Language 14
All families of health care consumers 11
Community Board members 4
 
The literature indicates that health promotion and education messages and activities are most effective when they are clearly targeted to a specific audience. And yet, in the Capital Health region, 84 organizations report that they are offering programs and activities that are targeted to the general public or all health care consumers.

Media Used

The following table illustrates the primary medium used by organizations within the Capital Health region to support the provision of health promotion programs. In line with the previous comments on low literacy and English as a second language, the vast majority of health promotion activities are English-based, and most are supported by print material of some kind.
 
Medium Used Number of Organizations Reporting
Print material (e.g., brochures, handouts) 84
Group face-to-face (seminars/workshops/courses) 65
Newspaper/magazine or other publications 58
Resource Centres (and other combination activities) 50
Individual face-to-face (counselling, demonstrating, etc.) 45
Telephone (e.g., hotlines, referral lines) 40
Poster/sticker or other campaigns 34
Electronic Dissemination (e.g., Internet) 28
Television (public service announcements, special programs, paid advertising, community channels, etc.) 26
Libraries 26
Mass or targeted mail-outs to consumers 16
Facilitation of Mutual Aid/Self-help 11
 
The literature on health promotion effectiveness indicates that print materials are most suitable for "main-stream", middle class groups who have the skills and resources to make use of print-based information. Individuals who are low income, disadvantaged, have low literacy skills, or who have English as a second language generally have difficulty benefiting from print based information activities. By far the majority of activities summarized in the above table are based on print materials and the ability to read. One attraction for these approaches, particularly brochures, handouts, or other print materials is the simplicity of production and duplication as well as the relatively low cost per individual covered and the ease of duplication. For example, it only costs a few cents to give someone a brochure on Canada's Food Guide whereas it costs significantly more per participant to establish a collective kitchen or offer a group counselling session on nutrition. However, the easy, lower cost approach will not be at all effective for certain target groups. One of he most effective ways of changing behaviour is the facilitation of mutual aid or self-help where the approach provides skills and support rather than being based on print materials. Only 11 organizations reported that this was the approach that was being used.

The Centre for Well Being has been funded to act as a resource for providers using current Internet technology (among other activities). However, many organizations who have provided information to the Centre cannot access the information. Of the organizations contacted in this study, only 15 had publicly accessible web sites, and only 26 of the contact people and/or their organization could be contacted through e-mail. The Centre is considering a number of options, including the possibility of distributing printed material in order to increase the access to the information they are collecting.

In many of the personal interviews, a great sense of frustration was expressed that the technology for quick and easy contact between organizations was available, but that the organization was not "wired" either because there were no computers, or there was no Internet/e-mail access. The Internet was noted as an effective mechanism for consumer and provider health promotion information as well as virtual support groups and electronic "communities" for individuals. However, even resource centres had difficult obtaining access to the necessary computer equipment and Internet access to make this resource available to the public. The Edmonton Public Library is one of the limited locations which provides free publically available access to the Internet and the world of resources it opens up. Capital Health is in the process of placing an emphasis on this form of information provision.

Evaluation Methods

 
Methods of Determining Effectiveness Number of Organizations Reporting
Formal evaluation projects 64
Consumer satisfaction measures (e.g., surveys) 52
Consumer complaints/requests monitoring 45
Demand for service monitoring 38
 
All of the organizations contacted consistently used some mechanism to monitor their activities. A full third of the organizations contacted used formal evaluation projects to determine effectiveness. Several organizations commented on the positive influence Capital Health has had by facilitating, encouraging and funding evaluation activities. However, many organizations commented that they primarily were "demand monitors" and lacked the knowledge and skills to appropriately evaluate the effectiveness of health promotion programs. One of the emphases in overall health reform strategy for Capital Health is to move increasingly toward evidence-based decision making, firmly grounded in research, evaluation and experiential knowledge. However, some community agencies partnering with Capital Health continue to lack the tools and resources with which to fully evaluate their programs.

Source of Funding

During the course of the interviewing, organizations were very open regarding the sources of funding that they obtained to support their programs. Most organizations relied on several sources of funding.
 
Sources of Funding Number of Organizations Reporting
Federal/provincial and municipal government bodies 55
Fees 37
Donations 32
Wildrose Foundation, United Way (and other grants) 23
Fund-raising 21
Other sources of funding 17
Capital Health  15
Health Canada 7
Alberta Health 6
 
One fear has been raised publicly by many community agencies over the last few years: as government budget restrictions occur, community agencies are forced to rely more heavily on donations, fees, and other fund-raising mechanisms to support their programs. This is partially the case with "seed" money or demonstration projects. Often, at the conclusion of the project (or the funding) even successful projects are left without funding. For some organizations, the issue of continued funding begs the question of sustainability of projects, a key factor to ensure continued effectiveness of health education and promotion activities.

Thirty-seven organizations report that fees (program entrance charges, purchase of materials, etc.) form part of the funding for their health promotion and education activities. Fees act as a barrier to many low income individuals who may benefit most from accessing these programs.

Health Determinant Focus

There is an increasing focus within the health promotion community on the underlying determinants of health. The following determinants of health were selected by the Federal, Provincial and Territorial Ministers of Health at their annual meeting in Halifax, September 14-15, 1994. Each organizational activity was categorized after the fact according to these determinants. By far the largest group of organizations involved in health promotion and health education (nearly three-quarters of the contacted organizations) deal with personal health practices and coping skills, followed by another quarter of the organizations who deal with social support networks in one way or another.
 
Focus on Health Determinant Number of Organizations Reporting
Personal Health Practices and Coping Skills 98
Social Support Networks 33
Healthy Child Development 21
Health Services 20
Education 15
Working Conditions 6
Physical Environment 3
Income and Social Status None
Biology and Genetics 1
 
A key role for Capital Health is in mitigating the effects of these health determinants. Capital Health must respond through the primary care, acute care and continuing care systems to the poor health which results from poor or delayed child development and genetically based illnesses, disabilities and conditions as well as the ill-health which often accompanies low income and low levels of education. While other sectors have the primary responsibility for addressing population income and education levels, Capital Health continues to have the responsibility for the "fall-out" which occurs in the health system when income and education targets are not reached.

One of the critical understandings about health determinants is that the health sector, and more particularly, the health promotion and protection sector within the health sector, is a key partner in addressing the determinants of health, and must work closely with other sectors, particularly education and social services to achieve effective results.

Areas for Emphasis

There are three primary areas which were mentioned repeatedly during the interviewing process which are seen as requiring additional attention. Children's Mental Health services was a particularly common response to open-ended questions regarding continued gaps in services.  
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CHAPTER 4 - PARTNERSHIPS IN THE CAPITAL HEALTH REGION

 Partners in Health Education and Promotion Services

 The literature emphasizes the need for a multi-sectoral, multi-disciplinary approach which involves the community in order to maximize the effectiveness of health education and promotions activities. Thus, partnerships are critical in order to engage the community, and broaden the base of involvement and sustainability. The graphic on page 4 illustrates the key partners who, with Capital Health, provide health promotion and education services within the Capital Health region. These groups include:
  1. Local Agencies and Providers - The most extensive partnership network connects Capital Health with the multitude of local agencies and organizations which are involved in the provision of health education and promotion services. This network supports the multi-sectoral, community-based approach required for effective delivery of services and activities.
  2. Provincial Level NGO's (Non-Government Organizations) - Many, if not most, province-wide NGO's are based within the Capital Health region. This group would include organizations such as the Alberta Association for Community Living, the Alberta chapter of the Canadian Mental Health Association, Action on Smoking and Health, the Alberta Public Health Association, Centre for Well-Being, Centre for Injury Prevention, etc.. This fact of physical location differentiates Capital Health from other regions in the potential and actual roles and relationships which the regional authority has, or could have, with regard to province-wide NGO's.

    3.  
  3. Municipal and Regional Boards and Governments - This group includes the municipal boards and administration of the city of Edmonton and St. Albert as well as the County of Strathcona. Also included in this category would be other elected or appointed boards (and their administrations) such as the seven public and separate school boards within the Capital Health region, library boards, and other regional boards such as the proposed regional structures for the Office of the Commissioner for Children's Services.

    4.  
  4. Federal and Provincial Government Departments - Capital Health's board and officials work with officials in both federal and provincial government departments, particularly Alberta Health and Health Canada, but also including Alberta Family and Social Services, Alberta Education, Alberta Community Development, the Workers' Compensation Board and AADAC, etc.

    5.  
  5. Professional Organizations - Most province-wide professional organizations are based in the Capital Health region. Partnerships with organizations such as the Alberta Medical Association, the College of Physicians and Surgeons, and the Alberta Nurses Association, facilitate a multi-disciplinary approach to local community development.

    6.  
  6. Other Regions - Capital Health has a variety of relationships with other regions, through both formal structures (Council of Chairs, Council of Medical Officers of Health, Council of CEOs, etc.) and other informal mechanisms. Of particular interest here are the "ring" regions of Aspen, Lakeland, Westview, Crossroads, and East Central. The residents of these regions are frequent visitors to the Capital Health region to obtain health services of various kinds, including taking part in health promotion activities. In addition, providers from other regions often look toward Capital Health as a source of information, innovative ideas and approaches.

    7.  
  7. Other Components within Capital Health - there are many components to Capital Health which are not directly involved in health promotion. Effective linkages between the health promotion components of Capital Health with the remainder of the organization are critical to ensure that goals and priorities are held in common.

    8.  
A sampling of organizations and individuals covering all of these groups (with the exception of elected officials) were interviewed as part of this project.

Roles of Capital Health

A key focus of the personal interviews which were conducted with some of the primary partners of Capital Health was the perceived role of Capital Health in the Edmonton region. Many roles were identified, singly and in combination, which described the relationship between individual organizations and agencies and Capital Health. These roles include:
It is clear that the many roles played by Capital Health within the region are complex and multifaceted. The key roles which were most frequently mentioned include: leader, partner, coordinator and funder. However, the current business planning documents for Capital Health focus only on the role of the authority in directly providing health promotion and education services rather than facilitating and supporting the activities of other organizations. It became obvious as the interviews were conducted that the changing role of Alberta Health over the past few years has influenced both the expectations and the reality of the partnership roles with Capital Health. There were certain functions which had historically been the responsibility of Alberta Health, including overall coordination, provision of a clearinghouse function, a catalyst for new initiatives, promulgation of best practices, and facilitation of collaboration, particularly across various regions in the province. With the role of Alberta Health changing, plus the downsizing which has significantly affected the number of health promotion specialists in Alberta Health, many organizations within the Capital Health region are searching for a replacement organization to undertake these functions. Organizations which have been suggested as potential replacements include: the Council of Chairs, the Alberta Public Health Association, the Centre for Well-Being, and Capital Health itself, none of which have the resources to meet the demand. Organizations are lamenting the lack of a single source of information and assistance for consumers searching for health promotion assistance as well as providers developing and implementing programs, which in turn raises concerns that scarce resources are possibly being expended on "reinventing the wheel". Chapter 5 of this report, Summary and Conclusions, on page 27, addresses potential solutions to these issues in more detail.

It became clear that the view of Capital Health by the large organizations (which are funders in their own right), such as Health Canada, Alberta Health, AADAC, school boards, municipalities, etc., differed somewhat from the view of Capital Health by smaller "grass-roots" organizations. Larger organizations saw themselves in a clear partnership role, with equal authority on both sides, and with the ability to contribute to Capital Health initiatives and priorities from their own sector. Similarly, Capital Health was expected to partner with them to in areas of particular need and on issues of common priority. Recent initiatives by Capital Health to open up communication channels with the school boards was extremely well received by the organizations involved.

Smaller organizations on the other hand tended to differ in whether they saw the relationship between themselves and Capital Health as a two-way street or whether the relationship was more one-dimensional. Capital Health was seen primarily as a source of funding, support and advice.. The most definite difference was the call by the larger organizations for overall regional planning processes in the area of health promotion. The smaller organizations were more concerned with the effectiveness of specific individual initiatives delivered by that organization rather than the way those initiatives fit into the overall regional continuum of services.

Some organizations suggested that many of the existing committees seem to deal with the same issues from slightly differing perspectives, yet some issues cannot easily find a forum. Historical structures which supported planning, decision-making and dissemination of ideas and practices no longer exist, and effective replacement forums have not yet grown into place. It is well understood that the northern and surrounding regions use Capital Health services extensively in the area of treatment and diagnosis, and specialized continuing care. This is taken into account in the new population funding method for budget allocation. However, there has been little attention paid to the use of health promotion services, particularly by residents of neighbouring regions. It is also understood that surrounding and northern regions tend to see the Capital Health region as demonstrating many best practices and as a source of provider training. With the change in mandate for Alberta Health, there is a void in the area of cross-regional coordination.

Dichotomies in Direction

There is more attention, or at least lip service, being paid to population health, health education and health promotion than ever before. However, this is coupled with an interesting, and puzzling, fact - at the same time that significant verbal commitment is given to the concepts and effectiveness of health promotion as an overall strategy, many organizations are reporting that organizational supports, such as consultant staff, have been reduced. In other words, although health promotion activities at the "grass-roots" level seem to be increasing, health promotion infrastructures have been weakened or dismantled in the wake of budget cutbacks and organizational downsizing.

There is an old adage that is certainly true in this case: When you are up to your knees in alligators, it is hard to remember that you set out to drain the swamp. In the context of health care in the Capital Health region, acute care deals with the alligators - health promotion is attempting to drain the swamp.

The individuals who received face-to-face interviews as part of this study usually represented the most senior person(s) in each organization who was responsible for health promotion activities, and each person overwhelmingly supported the concepts of health education and health promotion, as well as applauding the fact that Capital Health was even undertaking this study. It is, therefore, not surprising that these individuals, given their responsibilities, gave health promotion a high priority. If the overall organization was examined, however, health promotion may have a somewhat lower priority compared to the "main" business of the organization, whether that was provision of educational core curriculum services, treatment of ill-health or provision of municipal services.

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    CHAPTER 5 - SUMMARY AND CONCLUSIONS

Directions for the Future

The health sector has a specific role to play in dealing with health determinants and population health. As part of the analytic process, every attempt was made to consider whether any other organization or jurisdiction was more appropriately responsible for certain areas which seemed to require action. In particular, the new role of Alberta Health, as well as other provincial and municipal government departments and agencies, played a large part in the consultants' deliberations. Recommendations for action by Capital Health in this section focus on the overall areas within the health sector which seem to require the most attention.

Many Capital Health board members and officials currently act as stakeholders, advisors and influencers in the overall development of healthy public policy at the municipal, regional and provincial level. Although this occurs most often in the area of health policy, Capital Health representatives also consult on the development of environmental, social, cultural and other public policy at the municipal, provincial and federal level.

Capital Health is in an excellent position to provide leadership within the Capital Health region by using existing public policy forums, such as the Linkages Committee with the Officer of the Commissioner of Services to Children. The Canadian Public Health Association(3) suggests five areas which must be addressed in the development of healthy public policy:

The primary responsibility for creating supportive environments is shared between Capital Health and many other regional, provincial and national organizations. Some of those organizations include Alberta Labour (Occupational Health and Safety), Alberta Environment and Environment Canada, Alberta Family and Social Services and Human Resources and Development Canada, Workers Compensation Board, Alberta Health and Health Canada, and municipalities within the Capital Health region to name a few. However, there are two strategies which are directly within the purview of Capital Health. There is a wealth of resources available within the Capital Health region which address the development of personal skills. Improved access by consumers to these resources, through an enhanced information network, as suggested in an earlier recommendation, will result in increased effectiveness of these health promoting strategies on overall population health.

One key area for partnering for Capital Health which will be developing over the next few months is the opportunity to work closely with Alberta Education in the redevelopment of the Health curriculum for the K-to-12 school system. This may be an opportunity to address the concept of "healthy schools" in addition to an information-based health education process.

The Alberta Health and regional business plans produced over the last few years demonstrate a marked change in approach to the health system in Alberta, shifting from a focus on the treatment of disease to a focus on the promotion of health, emphasizing individual and community responsibility for individual and population health. Health organizations, particularly Alberta Health, are reorganizing to place the emphasis on leadership through specification of health outcomes, rather than administration of health services delivery. However, until this switch in focus to a population health approach permeates all sections of the health system, the reorientation to a wellness based health system will not occur.

There is some concern, expressed during some of the interviews, that all areas within Capital Health need to embrace the new focus on population health and health promotion. The literature suggests that one of the greatest barriers to implementing any reorientation of health services is the culture of institutions and health professionals who need to pay attention to the broader health issues (e.g., culture, poverty, literacy, social isolation) in their own health practices and their own working environments.

Part of the issue relates to the dissemination of information regarding the effectiveness of health promotion activities vis-a-vis over all costs of health services. Most evaluation and research activities which are carried out in the health promotion field are limited to the short to-medium term. In addition, most evaluation and research work is focussed on best practices for specific health promotion activities. And yet, the most effective and comprehensive strategies often only demonstrate their effectiveness in combination and over the long-term.

Action Plan

This report has demonstrated that the issue for Capital Health is not lack of action in addressing population health and health promotion issues within the Capital Health region. And, what is needed is not "more of the same". To increase the effectiveness of the overall health promotion sector within the Capital Health region, the "action" must be focussed on reaching more individuals both within the health sector and within the general population. There are five key strategies which would reorient activities to meet the highest priority needs:
    1. Establishment of a multi-sectoral regional planning process within the Capital Health region, under the leadership of Capital Health, to ensure that the major partners in the health promotion field have a coordinated approach to health promotion and population health. This would ensure that:
      1. Overlaps in mandate and services are minimized
      2. Public involvement is maximized
      3. Gaps are identified and filled
      4. Available resources are focussed on the highest priority areas (such as Children's Mental Health)
      5. Services are matched to demand
      6. Priorities are mutually established in order to focus activities

        7.  
    2. Establish key strategic partnerships with school boards within the Capital Health region to strengthen the role of health education and promotion within the school systems to ensure that effective health education and promotion strategies are in place at the earliest possible age, including:
      1. Strengthening the Health Education curriculum
      2. Establishing a more comprehensive approach to issues that require more than a health education approach, e.g., tobacco use, violence, sexual health.
      3. Broadening the health services which are delivered through the school system

        4.  
    3. Partner with community agencies, libraries and resource centres within the Capital Health region to improve access to information and services for health care consumers and the general public.

      4.  
    4. Continue to support community agencies by:
      1. Involving key partners in joint planning to deal with high priority issues
      2. Supporting community leadership and control
      3. Emphasizing "best practices"
      4. Prioritizing funding to focus on key health determinants
      5. Facilitating the establishment of training programs for community members and providers on needs assessment, planning and evaluation methodologies

        6.  
    5. Support, and supplement where necessary, the activities of the Injury Prevention Centre, the Tobacco Control Centre, and the Centre for Well-Being in the establishment of an easily accessible information clearinghouse and planning network for health providers to:
      1. Share information on best practices
      2. Demonstrate the impacts of effective health education and promotion strategies
      3. Assist in program design, research and evaluation
     
There are a multitude of health promotion resources and activities available within the Capital Health region. The responsiveness of local agencies and organizations to community needs and the growing response to community-based action is welcomed and supported by all organizations contacted. The action plan identified above will make it possible to build on current successes and continue to reorient health services to eventually improve population health and thereby reduce the burden on the acute care system.

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     APPENDIX 1 - SUMMARY OF RECOMMENDATIONS

     
     
    Recommendation 1: Capital Health should develop an information network for the use of both consumers and providers by using media, information processing, communication technologies, and other approaches to improve access, at anytime and from anywhere, to legitimate and useful information regarding health promotion. This should include forging closer links with key educational and social services organizations and agencies.

    Recommendation 2: Capital Health should develop a collaborative network among citizens who play key roles in health promotion and among health-focussed citizens groups of diverse types and sizes, to involve community members in the development of improved information access mechanisms.

    Recommendation 3: Capital Health should encourage use of electronic communications technologies, particularly for providers. This could include promoting e-mail communication between Capital Health and community agencies and organizations, providing an electronic bulletin board system for posting of health promotion information of general interest, establishing a mail list server for practitioners and community agencies on health education and promotion topics, increasing the number of links on the Capital Health web-site, hosting electronic discussion groups or increasing the public access to the Internet.

    Recommendation 4: Capital Health should redevelop its own web site to make it a more effective health education and promotion tool, including provision of the maximum amount of information regarding resources and activities available within the Capital Health region, promulgation of "best practices", sharing of key evaluation and research findings, and establishment of outcome and other indicators.

    Recommendation 5: Capital Health would benefit from working closely with research partners such as the Health Research Consortium, faculty at the University of Alberta, the Alberta Heritage Foundation for Medical Research, and the Centre for Well Being, to build a base for excellence in health education and promotion and would be valuable partners to expand the research and knowledge base for best practice in the Capital region.

    Recommendation 6: Capital Health should work with other key funders to expand support and build the capacity for community agencies to carry out program evaluation on health education and promotion initiatives.

    Recommendation 7: In cooperation with other organizations for whom children are a primary concern (such as the Provincial Mental Health Board, the Office of the Commissioner for Children's Services, school districts and Community Services), Capital Health should increase the emphasis on children's mental health services

    Recommendation 8: Capital Health should broaden access to the wealth of health education and promotion information and activities to individuals with low literacy levels. Experiential programs rather than print-based programs have proved effective. Print resources that are used should be presented in plain language, or through audio tapes.

    Recommendation 9: For consumers who experience language barriers, continued support for interpreter services and the use of cultural brokers to provide appropriate information and education opportunities is recommended.

    Recommendation 10: Capital Health should review its mandate and role in the provision of health education and promotion services within the Capital Health region to formalize and emphasize the aspects of leadership, partnership and coordination. This aspect of Capital Health responsibility should be built into plannning documents.

    Recommendation 11: Capital Health should consult with key organizations in the Capital Health region to develop improved linkages and set priorities regarding overall regional planning for the continuum of health education and promotion services.

    Recommendation 12: Capital Health may want to consider "strategic partnering", ensuring that key partners and forums which address issues of high priority to Capital Health receive the maximum support in terms of staff time and resources.

    Recommendation 13: Capital Health should recognize the reality of its leadership and coordination role with other regions and consider establishing a forum for multi-regional planning for the northern and surrounding regions for health education and promotion strategies which are in place in closely bordering communities around Edmonton.

    Recommendation 14: Capital Health should consider mechanisms to raise the profile of health promotion within large organizations to ensure that the overall infrastructures, including budgets, policy, partnership incentives and staff resources, are protected as much as possible.

    Recommendation 15: Capital Health should consider mechanisms to encourage input from local health promotion agencies and organizations regarding issues and options for the further development of healthy public policy which can be forwarded through the normal channels and forums available to Capital Health with regional, provincial, federal and municipal organizations.

    Recommendation 16: Capital Health should ensure a continued close working relationship between key branches within the Capital Health organization, such as Regional Public Health, Community and Acute Care Services to ensure consistency of approach and complementary focus on creating supportive environments within the Capital Health region.

    Recommendation 17: Capital Health should consider becoming a champion for the concepts of population health promotion with other organizations, to assist in the development of congruent goals between Capital Health and key organizations more directly concerned with supportive environments.

    Recommendation 18: Although high-level commitment to a health promotion approach to population health already exists within Capital Health, continued commitment to research and evaluation in the health promotion area, and the broad dissemination of results throughout the region, will assist in reorienting health services to a population health approach.
     

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    APPENDIX 2 - FRAMEWORK FOR HEALTH PROMOTION IN CANADA

     

Cornerstones of Health Promotion in Canada

Definition of Health (WHO)

 Over the last few decades, there has been an increasing understanding of the fact that health is more than just the absence of sickness or ill-health. Rather, health must be seen as a positive resource for living. This project is based on the World Health Organization (WHO) definition of health:
    Health is a state of complete physical, mental and social well-being and not just the absence of disease or infirmity.

Determinants of Health

In 1994, the Federal, Provincial and Territorial Advisory Committee on Population Health prepared a background paper entitled Strategies for Population Health: Investing in the Health of Canadians. The population health framework and the strategic directions proposed in this paper were adopted by the Ministers of Health at their meeting in Halifax, Nova Scotia, on September 14-15, 1994. The intent of the strategy document was to identify areas for collaboration between the various levels of government in Canada by addressing a broad range of health determinants in a comprehensive and inter-related way. The following nine areas were selected as comprehensively describing the determinants of health(4):
     
These determinants of health are becoming the key policy focus for the 1990's and beyond.

Ottawa Charter

     
    In 1986, Canada hosted the First International Conference on Health Promotion, on behalf of the World Health Organization (WHO). The outcome of this conference was the production and acceptance of The Ottawa Charter on Health Promotion which defined the fundamental prerequisites of health as peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. The Ottawa Charter called for action in five inter-related areas which reflected the basic premise in the document that access to the prerequisites of health was a an issue which affected and was affected by many sectors of the population. The five strategy areas are:
 
  • Build Healthy Public Policy - reflects a multi-sectoral approach to ensure that health-promoting policy is developed and supported within all sectors.

    •  
     
    Health promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. Health promotion policy combines diverse but complementary approaches including legislattion, fiscal measures, taxation, and organizational change. It is coordinated action that leads to health, income and social policies that foster greater equity. Joint action contributes to ensuring safer and healthier goods and services, healthier public services and cleaner, more enjoyable environments. Health promotion in policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. The aim must be to make the easier choice for policy makers as well. 
    OTTAWA CHARTER ON HEALTH PROMOTION
     
     
  • Create Supportive Environments - targets on the many environments within which people live, including the physical, social, economic, cultural, and spiritual, and recognizes the rapidly changing nature of society with its many influences, including technology and the nature of work.
    •  
     
    Our societies are complex and interrelated. Health cannot be seperated from other goals. The inextricable links between people and their environment constitutes the basis for a socio-ecological approach to health. The overall guiding principle for the world, nations, regions, and communities alike, is the need to encourage reciprocal maintenance - to take care of each other, our communities, and our natural environment. The conservation of natural resources throughout the world should be emphasized as a global responsibility. Changing patterns of life, work, and leisure have a significant impact on health. Work and leisure should be a source of health for people. The way society organizes work should help create a healthy society. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable. Systematic assessment of the health impact of a rapidly changing environment - particularly in areas of technology, work, energy, production and urbanization is essential and must be followed by action to ensure positive benefit to the health of the public. The protection of natural and built environments and the conservation of natural resources must be addressed in any health promotion strategy. 
    OTTAWA CHARTER ON HEALTH PROMOTION
     
  • Strengthen Community Action - enables communities to become empowered in setting priorities and making decisions on health issues.

    •  
    Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the emmpowerment of communities, their ownership and control of their own endeavours and destinies. Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public participation and direction of health matters. This requires full and continuous access to informtion, earning opportunities for health, as well as funding support. 
     
    OTTAWA CHARTER ON HEALTH PROMOTION
     
     
  • Develop Personal Skills - enables individuals to gain the knowledge and skills to maintain and improve their health and well-being, including strengthening their long-term contributions to society.

    •  
     
    Health promotion supports personal and social development through providing information, education for health and enhancing life skills. By doing so, it increases the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health. Enabling people to learn throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. This has to be facilitated in school, home, work and community settings. Action is required through educational, professional, commercial, and voluntary bodies, and within the institutions themselves. 
    OTTAWA CHARTER ON HEALTH PROMOTION
     
  • Reorient Health Services - redirects health services to focus on the needs of the whole person and rethinks the roles of the providers and the users of health services.

    •  
     
    The responsibility for health promotion is health services is shared among individuals, community groups, health professionals, health service institutions, and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health service sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinicl and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. Reorienting health services requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services, which refocuses on the total needs of the individual as a whole person. 
    OTTAWA CHARTER ON HEALTH PROMOTION
     In addition, the 212 participants from 38 countries
    who attended the conference pledged the following:
    1. To move into the arena of healthy public policy, and to advocate a clear political commitment to health and equity in all sectors;
    2. To counteract the pressures towards harmful products, resource depletion, unhealthy living conditions and environments, and bad nutrition; and to focus attention on public health issues such as pollution, occupational hazards, housing and settlements;
    3. To respond to the health gap within and between societies, and to tackle the inequities in health produced by the rules and practices of these societies;
    4. To acknowledge people as the main health resource, to support and enable them to keep themselves, their families and friends healthy through financial and other means, and to accept the community as the essential voice in matters of its health, living conditions and well-being;
    5. To reorient health services and their resources towards the promotion of health; and to share power with other sectors, other disciplines, and most importantly, with people themselves.
    6. To recognize health and its maintenance as a major social investment and challenge; and to address the overall ecological issue of our ways of living.

      7.  
    The Ottawa Charter has been translated into 40 languages and serves as a guidepost for health promotion around the world.
     
     

    Implications of the Population Health Promotion Model

     Health Canada has combined the definition of health, the determinants of health and the strategies for health promotion into an overall model for planning and analysis of health promotion activities. By examining a jurisdiction's practices from the perspective of health determinants and health promotion strategies, as well as by the type of target group, gaps and overlaps in activity can be identified. The model can then be used to assist in developing future plans, either for as an overall system wide planning model, or at a local level for helping in needs assessment. The following graphic illustrates this model.
     

    This project used this model(5) to assist in the analysis of the activities in the area of health education and health promotion in the Capital Health region.

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    APPENDIX 3 - HEALTH-PROMOTING HOSPITALS NETWORK

     
    The Health Promoting Hospitals Movement:
    Working for Health
    Announcement of Vienna Conference

    The concept: a health promoting hospital tries to incorporate the concepts, values and standards of health promotion into the organizational structure and culture of the hospital. The goal is to improve the quality of health care, and the conditions for and satisfaction of the staff, patients and relatives. The method is to apply the principles of the Ottawa Charter for Health Promotion to
    develop the hospital in the ways expressed in the Budapest Declaration on Health Promoting Hospitals.

    The WHO European Project

    The objective of the WHO European Health Promoting Hospitals project is to promote a movement of hospitals throughout the WHO European Region:

     Approaches for Development

    Four approaches have been identified for developing health promoting hospitals in the European Region.

     Main Areas for Programme Development Health Promoting Hospitals European and thematic networks

    Full membership is open to hospitals that: endorse the principles of the Ottawa Charter for Health Promotion (LINK) and the Budapest Declaration on Health Promoting Hospitals as guidelines for action; and develop programmes or activities for health promotion based on the Budapest Declaration to introduce comprehensive organizational change.

    Affiliated members or observers include hospitals, other institutions and people that: endorse the principles of the Ottawa Charter for Health Promotion and the Budapest Declaration; and are interested in the development of the project, or in collaborating with hospitals in the project.

    Regional/National Networks Recognized by WHO

    Individual members must fulfil the requirements for full members of the Health Promoting Hospitals European Network. Each network defines its own requirements and conditions for membership. To secure membership or for more information, please contact the Ludwig Boltzmann Institute or the Hospitals Unit of the WHO Regional Office for Europe.

    Background

    The Health Promoting Hospitals Movement of the WHO Regional Office for Europe is a project of the Hospitals Unit of the Department of Health Policy and Services. The project started officially at a workshop on hospitals and health that was held in Vienna in 1990. It was established as a multi-city action plan of the WHO Healthy Cities project. The Ludwig Boltzmann Institute for the Sociology of Health and Medicine was appointed coordinating centre for the project. On the basis of the Ottawa Charter for Health Promotion and the experiences of the Healthy Cities project, the Budapest Declaration on Health Promoting Hospitals was developed at the first business meeting of the Health Promoting Hospitals Network, which was held in Budapest in 1991. The Declaration focuses on the content and aims of the member hospitals. Since then, other networks have been established to facilitate and encourage the development of the project.

    Business meetings and annual conferences are held to exchange information and experiences and to decide on the future developments of the project. A newsletter is published twice a year as well as various leaflets and information booklets.
     
    Management

    The Hospitals unit of the WHO Regional Office for Europe and the Ludwig Boltzmann Institute for the Sociology of Health and Medicine coordinate the project. The four networks are interrelated to maximize the benefits of exchanging experience with selected programmes and structures.

    Contacts

    For further information, contact:

    Hospitals Unit
    WHO Regional Office for Europe
    8 Scherfigsvej
    DK-2100 Copenhagen OE
    Denmark
    Tel: (45) 39 17 12 70
    Fax: (45) 39 17 18 65
    E-mail: mgb@who.dk or kja@who.dk

    Ludwig Boltzmann Institute for the Sociology of Health and Medicine
    WHO Collaborating Centre for Hospitals and Health Promotion
    Universitätsstrasse 7/2
    A-1010 Vienna
    Austria
    Tel: (43) 1 402 93 60 25
    Fax: (43) 1 403 93 63
    E-mail: hph.soc-gruwi@univie.ac.at
     
    © WHO Regional Office for Europe
    URL:http://www.who.dk/tech/hs/hphbroc.htm
    Updated 31 January 1997 - jfr@who.dk
     
     

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    APPENDIX 4 - PERSONAL INTERVIEWS

     
    Alberta Health
    Ron Dyke, Senior Team Leader, Health Policy
    Dennis Ostercamp, Barb Hanson

    Health Canada
    Penny Mosmann, Provincial Manager, Health Protection and Promotions Branch

    Alberta Education
    Gina Vivone-Vernon, Assistant Director, Humanities Unit, Health, CALM, Physical Education, and  ECS

    Alberta Public Health Association
    Phyllis Hodges, Executive Director

    Alberta Centre for Well-Being
    Cynthia Smith, Director

    Alberta Injury Prevention Centre
    Kathy Belton, Project Coordinator

    Alberta Alcohol and Drug Abuse Commission
    Brian Cairns, Executive Director

    Centre for Health Promotion Studies, University of Alberta
    Dr. Douglas R Wilson, Acting Chair

    Office of the Commissioner of Services for Children
    Hugh Nicholson, Regional Director, Edmonton, Planning and Development

    City of Edmonton, Community Services
    Wally Subczak, Innovative Services
    Pat Power, Public Education
     
    Caritas Group, Health Resources Centre
    Cheryl Barabash-Pope, Coordinator, Community Development and Health Promotion

    Strathcona County Health Centre
    Darlene Smith, Community Care and Public Health

    St Albert Public Health Centre
    Janet Thorpe, Manager

    Edmonton Catholic School Board
    Richard St. Arnaud, Director, School Operations Services

    Edmonton Public School Board
    Bruce McIntosh, Department Head, Program Operations, Monitoring and Planning

    Public Health Library, Capital Health
    Ann Vanden Born, Library Coordinator

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    APPENDIX 5 - BIBLIOGRAPHY

    Bruner, C., L. G. Kunesh and R. A. Knuth. What Does Research Say about Inter-agency
    Collaboration? North Central Regional Educational Laboratory, Oak Brook, 1992.

    Canadian Public Health Association. Action Statement for Health Promotion in Canada. July, 1996.

    Capital Health. Action for Health Annual Report. August 19, 1996.

    Capital Health. Action for Health Proposal Document. December 17, 1996.

    Capital Health. Highlights: Directions for Health - Directional Plan Update 1996 - 1999. January, 1996.

    Capital Health. Capital Health Authority Business Plan 1997/98 - 1999/2000. March, 1997.
    Edelman, Peter B. and Beryl A. Radin. Effective Services for Children and Families: Lessons from the Past and Strategies for the Future. Background Paper presented at the National Forum on the Future of Children and Families. 1991.

    Frank, John W. and J. Fraser Mustard. The Determinants of Health from a Historical Perspective. Daedalus, Journal of the American Academy of Arts and Sciences, Fall, 1995. Vol 123, No.4.

    Glass, Gene V. Primary, Secondary and Meta-Analysis of Research. Educational Researcher, November, 1976, pp.3-8.

    Golden, Olivia. Collaboration as a Means, Not an End: Serving Disadvantaged Families and Children. Background Paper presented at the National Forum on the Future of Children and Families. 1991.

    Gomby, Deanna S. et al. Long-Term Outcomes of Early Childhood Programs: Analysis and Recommendations. The Future of Children, Vol 5. No. 3, Winter, 1995.

    Halpern, Robert and Robert Myers. Effects of Early Childhood Intervention on Primary School Progress and Performance in the Developing Countries. Prepared for the Bureau for Program and Policy Coordination, United States Agency for International Development. April, 1985.

    Hamilton, Nancy and Tariq Bhatti. Health Promotion Development Division. Health Canada. Population Health Promotion: An Integrated Model of Population Health and Health Promotion. February, 1996.

    Hayward, Sarah, RN et.al. Public Health Nursing and Health Promotion: Background Paper. Prepared for the Ontario Health Evaluation Network, 1996.

    Hazel, Jane. Technological Advances and Their Uses for Social Marketing. Prepared for the Health Promotion Directorate, Health Canada. April, 1994.

    Health Canada. Building a Stronger Foundation: A Framework for Planning and Evaluating Community-Based Health Services in Canada. Background paper prepared for the Federal/Provincial/Territorial Deputy Ministers of Health by Margaret I. Wankel, L. Duncan Saunders, Raymond W. Pong, and W. John Church. 1995.

    Health Canada. Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies for Population Health: Investing in the Health of Canadians. Prepared for the Meeting of the Ministers of Health, Halifax, Nova Scotia, September 14-15, 1994.

    Health Canada. Program Promotion Division, Health Promotion Directorate. Health Programs and Services Branch. Social Marketing in Health Promotion. Compilation of key articles on Social Marketing. January, 1994.

    Horne, Tammy, Ph.D. A Comprehensive Approach to Promoting Healthy Early Childhood Development: Supporting Children, Parents and Communities. Background paper prepared for Capital Health. 1996.

    Michels, Katie, MHSc. Creating A Capacity for Change in Health Promotion and the Non-Profit Sector: A Discussion Paper on Healthy Organizational Change. Prepared for the Ontario Prevention Clearinghouse. July, 1996.

    National Forum on Health. Advancing the Dialogue on Health and Health Care: A Consultation Document. Internet source http://wwwnfh.hwc.ca/publicat/advancin/idxadva.htm.
    National Forum on Health. Canada Health Action: Building the Legacy. Final Report - Volume 1. February, 1997.

    National Forum on Health. Health and Health Care Issues - Summaries of Background Areas. Supplement to Canada Health Action: Building the Legacy. February, 1997.

    National Forum on Health. Report on Dialogue with Canadians: Health and Health Care. Internet source http://wwwnfh.hwc.ca/publicat/dialogue/idxdial.htm

    National Forum on Health. What Determines Health? Summaries of 26 papers on health determinates prepared for the National Forum on Health. Internet source http://wwwnfh.hwc.ca/publicat/execsumm/.

    National Forum on the Future of Children and Families. Schorr, Lisbeth B., Deborah Both, and Carol Copple, Editors. Effective Services for Young Children: Report of a Workshop. National Academy Press, Washington, DC, 1991.

    Nelson, Douglas W. The Role of Training and Technical Assistance in the Promotion of More Effective Services for Children. Background Paper presented at the National Forum on the Future of Children and Families. 1991

    Schorr, Lisbeth B. with Deborah Both. Attributes of Effective Services for Young Children: a Brief Survey of Current Knowledge and its Implications for Program and Policy Development. Background paper presented at the National Forum on the Future of Children and Families. 1991.
     
     
    1. Capital Health. Capital Health Authority Business Plan 1997/98 - 1999/2000. March, 1997.
    2. National Forum on Health. Canada Health Action: Building the Legacy. Final Report - Volume 1. February, 1997.
    3. Canadian Public Health Association. Action Statement for Health Promotion in Canada. July, 1996.
    4. Health Canada. Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies for Population Health: Investing in the Health of Canadians. Prepared for the Meeting of the Ministers of Health, Halifax, Nova Scotia, September 14-15, 1994.
    5. Hamilton, Nancy and Tariq Bhatti. Health Promotion Development Division. Health Canada. Population Health Promotion: An Integrated Model of Population Health and Health Promotion. February, 1996.

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