setting a foundation: underlying values and structures of health promotion in primary health care...

Introduction

Jurisdictions around the world (McElmurry et al.,2002), such as Australia (Victorian Department ofHuman Services, 2000), Britain (Adams et al., 2001;Gillam and Schamroth, 2002), Canada (Marriottand Mable, 2000), and New Zealand (King, 2001;Ministry of Health,New Zealand,2003),have articu-lated the need for development of an integratedhealth care system with increased emphasis on

primary health care, and incorporation of prin-ciples and practices of health promotion. Our articleelucidates the requisite dimensions of a health pro-motion philosophy and approach in primary healthcare settings.We provide a strategy and frameworkto support practical and attainable action. Our aimis to provide clarity and an operational definition to health promotion so that it can be practicallyaddressed.

Context and rationale

In recent decades, health promotion has developedin isolation and functioned separately from primary

Primary Health Care Research and Development 2006; 7: 172–182

© 2006 Edward Arnold (Publishers) Ltd 10.1191/1463423606pc279oa

Setting a foundation: underlying values andstructures of health promotion in primaryhealth care settingsC James Frankish Institute of Health Promotion Research, Faculty of Graduate Studies, Department of Health Careand Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, Glen MoultonInstitute of Health Promotion Research, University of British Columbia, Vancouver, BC, Canada, Irving RootmanFaculty of Human and Social Development, University of Victoria, Victoria, BC, Canada, Carol Cole and Diane GrayInstitute of Health Promotion Research, University of British Columbia, Vancouver, BC, Canada

Jurisdictions around the world have articulated a need for development of an inte-grated health care system with increased emphasis on primary health care and incorp-oration of the principles and practices of health promotion. To date, the medical modelhas been the default model of care. Yet, treatment alone is unlikely to have markedeffects on health inequities or health status. This article presents and discusses twofoundational dimensions (values, structures) of a health promotion philosophy andapproach in primary health care settings. We propose a strategy and framework to sup-port practical and attainable action. Our article (the first of a series of two) is based ona literature review, validation by key experts and a national survey of Canadian pri-mary health care settings. We argue that fundamental philosophical values provide afoundation for health promotion in primary health care. These values should bereflected in the structures that create a supportive environment for health promotion.Our remaining three domains (strategies, processes, outcomes) are presented in a second following article. Based on values and structures, we conclude that subsequentstrategies (interventions), processes (client- and community-centred care), and desiredhealth promotion outcomes (intended or unintended) may be achieved.

Key words: health care reform; health inequities; health promotion; population health;primary health care

Received: May 2004; accepted: December 2005

Address for correspondence: Glen Moulton, Institute of HealthPromotion Research, University of British Columbia, Room 411,LPC Building, 2206 East Mall,Vancouver, BC, Canada V6T 1Z3.Email: [email protected]

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Values & structures of health promotion in primary health care 173


care. More recently, the philosophy underpinninghealth promotion has become accepted more widely.Despite this apparent increase in awareness of andpredisposition toward a health promotion philoso-phy, health promotion remains largely on the fringesof primary health care.This is due to the preventiveand perceived, ‘non-urgent’ nature of health pro-motion when compared with clinical/medical care(Ziglio et al., 2000).The medical model has been thedefault model of care (McElmurry and Keeney,1999). Treatment alone is unlikely to have markedeffects on health inequities. It is only recently thatmany jurisdictions and health professionals haverecognized that a reduction in inequalities and aclosing of the gap in health status requires greaterintegration of health promotion in primary healthcare (HP in PHC) (Keleher, 2001; Ministry ofHealth, New Zealand, 2003). It has been estimatedthat health services only contribute about a fifth ofhealth improvement (Evans et al., 1994). Today’shealth problems demand a health promotionapproach. Health improvement mainly occursthrough changes in the social, economic, and cul-tural impacts on communities (King, 2001). A narrow technical approach is inadequate for inter-vening in health problems that have a social, eco-nomic, behavioural and/or psychological basis.Withincreased focus on health promotion,health servicesmay be a more effective determinant of health.

While HP in PHC is recognized as reasonable/beneficial, it is not easy to achieve. There remainsa disparate understanding of health promotionconcepts and the inherent diversity of potentialapplications (McElmurry and Keeney, 1999).Thereis a need for a strategic approach to guide pro-gramme planning, implementation, evaluation, edu-cation and research. Stakeholders need to maketheir conceptual framework/understandings ofhealth promotion more explicit and tangible.

Health promotion research in primary healthcare often focuses on only one or two of the manycomponents. This contributes to the maintenanceof diverse and fragmented perspectives. It is crit-ical that we identify and define terms and conceptsunderpinning HP in PHC. We can do so by differ-entiating it from the more predominant disease-focused model. By operationalizing the breadthand diversity of HP in PHC, settings may be ableto develop and sustain it.This fundamental changerequires a philosophical paradigm shift as well aspractical implementation.

Definition of primary health care

We recognize that the terms ‘primary care’ and‘primary health care’ are often used interchange-ably, and sometimes have different meanings fordifferent people. We use the definition of primaryhealth care suggested by the National (Canadian)Forum of Health: ‘The care provided at the firstlevel of contact with the health care system, thepoint at which health services are mobilized andcoordinated to promote health, prevent illness, carefor common illness, and manage health problems’(1998: 22).This definition includes a focus on a pri-mary (medical) care model, usually provided byfamily physicians, and a broader concept thatencompasses a range of health/social services pro-vided through multidisciplinary teams. Primaryhealth care is the natural entry-point to reorient ahealth system towards health promotion.

Primary health care providers include chiro-practors,dentists,dieticians, family physicians,healtheducators, midwives, nurses, nurse practitioners,optometrists, pharmacists, physiotherapists, psych-ologists, and social workers. Settings in which ahealth promotion philosophy/approach could beexpanded include community health centres, emer-gency rooms, outpatient clinics, pharmacies, privatesolo or group practices, public health units, healthvans, outreach centres, store-front settings, andwalk-in clinics.

While there has been considerable work doneon ‘health promoting hospitals,’ institutionalizedacute-care settings were not the focus of this project.While some settings may be more conducive toadopting a health promotion philosophy/practicethan others, we argue strongly that there is a roleand responsibility for providers in every setting toimplement health promotion.

Definition of health promotion

Despite some common definitions of health pro-motion (World Health Organization (WHO), 1986),we found that many people associated with primaryhealth care continue to understand the term ‘healthpromotion’ differently.This may contribute to con-tinuing confusion and a lack of consensus. Ourarticle highlights the need for great attention andclarity regarding the meaning of HP in PHC. It canbe a complex, sophisticated, vague and variable

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phenomenon within primary health care. Moreoften than not, health promotion is understood toonarrowly. Health education is often seen as the sum total of health promotion. This unfortunateperspective is common to health decision-makerslooking for simplistic behaviour change or one sizefits all interventions.

There are many published definitions of healthpromotion.The most widely cited and used through-out the world is that health promotion is ‘the processof enabling people to increase control over, and toimprove, their health’ (WHO, 1986).An elaborationof this definition has become popular, namely ‘theprocess of enabling [individuals and communities]to increase control over [the determinants of health]and [thereby] improve their health’ (Nutbeam,1998). These definitions have implications for theway in which health promotion is practiced in pri-mary health care settings. They imply that healthpromotion involves enabling or ‘empowering’people to address factors that affect their health.They imply that it does so by increasing their ‘con-trol’ over these factors or ‘determinants’.This mightbe accomplished by helping them obtain access toneeded resources, or by helping them develop personal and collective capacities. The definitionalso suggests that the desired outcome of healthpromotion is ‘improvement’ of health rather thansimply its maintenance. It implies that health is a‘positive’ concept that people need to strive toward.The use of the terms ‘individuals and communities’as a substitute for ‘people’ in the second definitionsuggests that health promotion is an enterprise orset of activities that is focused on individuals andthe communities where they live. We define com-munity as any group of citizens that have either ageographic, population-based, or self-defined rela-tionship and whose health may be improved by ahealth promotion approach. Similarly, we employthe term ‘client’ rather than patient because it de-medicalizes the issue of care, avoids notions ofdependence, and reflects a broader cadre of ser-vices or activities with which the individual may beinvolved beyond the simple receipt of treatment.

Research design

We consulted broadly, using qualitative and quan-titative methods, to construct a conceptual frame-work for HP in PHC that contains the most salient

characteristics of HP in PHC from dozens of pos-sibilities. Our research began with an extensivereview of the literature in journals using databases,such as MEDLINE, HaPI (Health & PsychosocialInstruments), CINAHL (Cumulative Index toNursing & Allied Health), PubMed, and Embase.We searched the terms ‘health promotion,’ ‘primaryhealth care,’ ‘primary care,’ ‘community healthcentres/centers,’ and ‘reorienting health services’separately and combined from 1990 to 2004. AnInternet search of 620 sites was done combiningsearch terms ‘health promotion’ and ‘primary care’or ‘primary health care.’ We retrieved a variety ofgrey literature, that is policy documents and reports.Our review yielded relevant materials from coun-tries throughout the world.

We then employed a modified Delphi techniquein which we convened experts to seek their opin-ions on the relevant characteristics of a conceptualframework of HP in PHC. Our experts included a team of researchers from the Health ReformWorking Group of the Canadian Consortium forHealth Promotion Research, as well as a multidisci-plinary advisory committee of practitioners/policymakers. It included individuals with internation-ally recognized expertise in health promotion and/or primary health care. The experts had diverseeducational backgrounds, such as nursing, medi-cine, social work, psychology, and education. Theywere employed in academia, health administrationand/or health service delivery. Based upon the lit-erature review and feedback from experts, aninterim conceptual framework was drafted and re-circulated to experts to start the next cycle ofseeking input/clarification. This process continueduntil experts were satisfied with the conceptualframework.

We then sought feedback on our interim frame-work from additional experts to enhance its trust-worthiness.A focus group was held in four Canadiancities (Toronto,Vancouver, Halifax and Edmonton).Forty-eight people participated. They includedhealth researchers/academics, health service prac-titioners, and policy makers with a variety of edu-cational training.

The final phase of our research was a nationalsurvey of primary health care settings to examinethe level of importance and activity that profes-sionals and administrators attributed to the variouscharacteristics of the conceptual framework. In thewinter of 2003, we conducted a survey of primary

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health care settings in Canada on the perceivedimportance and reported level of activity of thevalues, processes, structures, and outcomes ofhealth promotion within their setting. The ques-tionnaire was available online or in hardcopy. Itcontained quantitative and qualitative questions.Of the 331 English-speaking settings sampled, weobtained a response rate of 52% (N � 171) (110/184community health centres, 27/50 public healthunits, 15/48 family practice units, 4/6 hospital units,and 15/43 nurse practitioner units). This responserate is similar to surveys in other jurisdictions(Baum et al., 1998). Settings were recruited throughan Internet search and by contacting national/provincial organizations of health care profes-sionals and settings. We included provincial andnational associations of community health centres,regional health authorities, provincial/territorialMinistries of Health, and university-based familypractice units associated with 16 medical schools.Settings were faxed or emailed one to threereminders.

Our initial framework underwent a process ofrefinement with each successive research phase.The framework evolved substantially. The charac-teristics within the five domains (values, structures,strategies, processes, and outcomes) were modi-fied until no other aspects of HP in PHC could beidentified that were not already included in theframework. Each of the characteristics underwenta cyclical process: continuous discovery to identifypatterns; categorizing/ordering data; qualitativelyassessing the trustworthiness of data to refine patterns; and synthesizing the themes/concepts intocharacteristics of the framework (McMillan andSchumacher, 1997).

The underlying foundation of our conceptualframework is rooted in international documents,such as the Ottawa Charter of Health Promotion(WHO, 1986) and the Declaration of Alma-Ata(WHO, 1978). The use of international literatureand internationally renowned experts increases theoverall credibility and potential transferability ofthe conceptual framework to jurisdictions through-out the world. At a policy and practical level, theapplication of the conceptual framework will varyacross developed and developing countries, butwill also vary within countries and primary healthcare settings.The conceptual framework presentedrecognizes the evolving nature of health promotionand primary health care in all countries, regions and

settings due to economic, social, cultural and polit-ical conditions.

Key domains and characteristics of HP in PHC

The following section describes our conceptualframework of HP in PHC. The key characteristicsare clustered into five domains (values, structures,strategies, processes, and outcomes). Health pro-motion comprises multiple, interconnected con-cepts that need to be incorporated into the dailypractice of primary health care. We believe thatthe only way to truly engender health promotionis to integrate all domains and as many character-istics as applicable. The elements of our descrip-tive domains are neither mutually exclusive norindependent.

First, the philosophical values that provide thefoundation for HP in PHC are described. Next,we discuss how values might manifest in specificstructures. Structure describes the characteristicsof a primary care setting that create a ‘supportiveenvironment’ for health promotion. Our purpose isto present and discuss these two dimensions (values,structures) as a foundation for HP in PHC settings.The remaining domains (strategies, processes, out-comes) are presented in Moulton et al., 2006.

We offer an operational definition of each char-acteristic. HP in PHC is most effective when alldomains/characteristics are developed and coord-inated.The two domains are presented sequentially,but we recognize that the implied ‘linearity’ of ourmodel belies its true iterative nature. The frame-work is neither definitive nor prescriptive,but ratherenabling since the priorities for individual regions/settings will vary and need to be adjusted accord-ingly. No single detailed step by step guide for useby primary care agencies is suggested, but key com-ponents for ensuring quality health promotion areoutlined.They are deliberately flexible to allow forcreative programming, since a ‘one size fits all’approach is counterintuitive to health promotion.None of the dimensions within the two domainsare unique to health promotion per se. Health pro-motion is unique precisely because it is an amalgamof values/practices that enhance health. The infor-mation provided exemplifies the breadth of thesubject area and is condensed into the shortestformat possible, using simple language. (This has

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repeatedly been identified as a priority amongstakeholders.) Practitioners and decision-makersmay require additional information about particu-lar areas of interest to acquire sufficient depth.

ValuesPeople working in primary care and/or health

promotion share common culturally transmitted val-ues regarding health/health services. These valuesare fundamental in affecting which health issues are addressed, and the strategies that we employ.Values/norms within an organization are oftenimplicit and may be ignored or overlooked in think-ing of health promotion.

Broad view of health and its determinantsHealth is influenced by more than just provision

of health care. Health promotion subscribes to a positive, multidimensional view of health thatfocuses on the whole (ie, physical, mental, social)person or the community. It recognizes the role of broad determinants (eg, income, social support,education, employment or working conditions,housing, food security, social environments, physicalenvironments, health practices, coping skills, childdevelopment, gender, culture, biology/genetics,health services) in creating/maintaining health andquality of life. These determinants may each inter-act with one another. We cannot simply promotethat individuals change their attitudes and lifestyles,when the environment in which they live and workprovides little or no choice or support. Immediateproblems of finances, food, and shelter may be sodominant that long-term considerations of healthare irrelevant. To better incorporate health pro-motion values, the practice of primary care mustaddress causal circumstances, not just treatment.Action is based in the social and cultural context.

Optimal health and quality of life for allHealth is more than the absence of disease or dis-

ability; it includes vulnerability to disease and dis-ability. Health promotion is concerned with healthproblems before they develop or worsen, not onlyafter they appear. Health promotion aims to reducedifferences in health status and vulnerability, andto ensure equal opportunities and resources toenable all people to achieve their fullest healthpotential and quality of life.

EmpowermentHealth promotion is the process of enabling

individuals and communities to increase controlover, and to improve their health. It demands themeaningful participation of affected individuals inplanning, implementation and evaluation of inter-ventions intended to improve their health andquality of life. People cannot achieve their fullpotential unless they are able to take control of thosethings that determine their health. Empowermenthas a psychological and a community perspective.The former is concerned with self-esteem/self-efficacy, and the latter is concerned with politicalaction. Health promotion emphasizes ‘power-with’rather than ‘power-over’.

Social justice and equityHealth promotion is concerned with removing

disparities in health and access to its determinantsfor disadvantaged/at-risk populations. It places apremium on social justice, diversity, fairness, andremoval of barriers to equitable participation inaspects of society that influence health and qualityof life, including access to health services. Accessto health and its determinants should be based onneed (and not demand),and attention must be givento people’s social realities. While there is a needfor self-responsibility and changes in knowledge,attitudes and behaviours, people cannot be reliantupon economic, social or cultural resources theydo not possess.

Social and environmental sustainabilityHealth promotion subscribes to a ‘stewardship’

ethic that recognizes responsibility for the healthof present/future generations and judicious, sus-tainable use of human and natural resources. Theinextricable links between health (or illness) andpeople’s human/natural environments create a basisfor an ecological approach to health. Health pro-motion protects the interface between the human,natural, social, economic, and built environments,through appropriate land use planning, transporta-tion planning, sanitation, safe water, clean air, safefood supply, and proper nutrition.

Social capital and healthy communitiesSocial capital is a concept that recognizes the

value and need for a civil society, that a range of social/community circumstances can influencehealth, and that individual/community health and



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well-being can be affected by the way people relateto each other. Indicators of social capital includecommunity/ civic participation, social relationships,social support, reciprocal activities and levels oftrust in others.

IntegrationHealth promotion is integrative in three ways:

it subscribes to a holistic, systems view of healthand quality of life; it seeks to bring together indi-viduals and communities in efforts to maximizetheir health; and it aims to integrate a health pro-motion perspective into societal institutions.Thereis a need for horizontal integration (ie, links betweenprimary health care and other sectors of society)and vertical integration (ie, links between clients,front line service providers and decision leadersand communities, within and across nations).

Appropriate models and methods for accountability

Interventions designed to influence health/qualityof life must be accountable (appropriate, relevant,useful) not only to clients, but for the health of thecommunity and to society as a whole. HP in PHCis a shared responsibility among individuals, pro-fessionals, community groups, health service insti-tutions and all levels of government.To date, manyof the models, standards and methods for account-ability in primary care settings do not fit within ahealth promotion, community context.All forms ofevidence are a social construction.Qualitative and/orquantitative approaches should be used and valuedas the situation demands. Health promotion valuesindigenous knowledge and practices, and seeks toachieve positive societal change while respectingexisting cultural groups and communities.

StructuresThe structures domain describes the characteris-

tics of the primary health care setting that create a supportive environment for health promotion.Health promotion will remain marginalized if it isrelegated to one person in an organization or onlydeveloped as an ad hoc project outside of corestructures of primary health care.

Values and intention alone are not sufficient toestablish a health promotion approach. Creatingorganizational structures (supports) builds opti-mal conditions for success/sustainability of health

promotion by ensuring that the programmes, pol-icies, and practices of an organization reflect its pur-pose, values and objectives. The process of changetoward a health promotion approach requires concerted/sustained action made incrementally toallow providers to continue to provide care whilechanging how they deliver that care (Nova ScotiaDepartment of Health, 2001). By building on suc-cessful initiatives in a stepwise, evolutionary man-ner,health promotion can be brought to the forefrontof primary health care. Integrating HP in PHCinvolves delivery of strategies aimed at specific targetpopulations and health issues (see Moulton et al.,2006), within broader efforts to build the capacity oforganizations and communities to promote health.

Resource allocationThe resource allocation for health promotion

has typically been too little for sustainable action(Ziglio et al., 2000). Primary health care organiza-tions need funding that reflects the relative healthpromotion needs of their populations, taking intoaccount factors such as age, sex, deprivation level,ethnicity, and determinants of health. For example,some jurisdictions allocate a minimum of 20% oftheir budgets for health promotion (VictorianDepartment of Human Services, 2000).

Committed personnelManagement’s commitment to, and understand-

ing of, health promotion is often a first vital step in developing an organization wide approach. Themost effective champions are often those in mid-upper management positions with a sense of lead-ership, motivation, compromise and appropriatenegotiation skills (Marshall and Craft, 2000). Ahealth promotion coordinator can play a vital rolein educating/supporting staff, driving organizationalinitiatives and liaising with community agencies.A case manager can ensure that services receivedby clients are integrated and appropriate so clientsare not required to navigate through a maze ofagencies. They may be responsible for team lead-ership and case coordination. Some jurisdictionsrequire each provider to spend a set portion of theirtime (eg, 20%) on health promotion (Swaby andBiesot, 2001).

Human resources development(capacity building)

Training for health professionals prioritizesacquisition of technical and practical skills. Health

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professionals are being encouraged to practicehealth promotion as if it were a straightforward andinnate phenomenon (Keleher, 2001). Health pro-motion demands a skill set that is distinct fromclinical practice but one that is just as complex andworthy of study and practice. Health professionals,especially physicians, often endorse the principleof prevention, yet nonetheless view it as a low status activity, and may seek to limit their owninvolvement by delegation to others (Adams et al.,2001). When a non-medical (but health-related)issue is identified, the tendency among health careprofessionals is to acknowledge it and move on to more clinically related topics where they feelthey have specific expertise (Cashman et al., 2001).Human resources development in health promotionincludes training and education to enhance know-ledge and skills of individuals to enable them toperform effectively while accommodating diver-sity in differences in backgrounds, clinical practice,educational needs, and learning styles. This may consist of in service training, on the job training/mentoring, and continuing education.

Intersectoral collaborationCross-cutting health issues cannot be tackled by

agencies operating in isolation. Partnerships andcoalitions are essential to address social and eco-nomic factors that mediate health status differ-ences, and to generate community-based solutionsto health problems. Partnerships must be activelysought with organizations that may not have anexplicit health focus, and requires co-operationamong many levels of stakeholders – national gov-ernments, regional governments, local governments,local organizations, private sector, and (potential)clients. Genuine partnerships require moving out-side ‘zones of comfort’ and a substantial degree ofcommitment and trust among partners.

AccessibilityHealth promotion recognizes a fundamental dis-

tinction between availability and accessibility. Acore problem in primary care is that many servicescontinue to be inaccessible for marginalized popu-lations. Health/social services should be providedas close as possible to where people live and/orwork without socioeconomic, geographic, culturaland other barriers, ensuring that health and socialservices are available, affordable, appropriate,and acceptable for those whose health needs are

greatest. Examples to enhance accessibility includemobile/outreach services, extended office hours,drop-in appointments, translators and appropriatepamphlets.

AccountabilityA process for monitoring progress in a health

promotion approach ensures accountability andgives attention to how progress is recorded andreported, to whom, how often, and what actionswill be taken if the strategy is facing difficulties or isnot implemented (eg, Continuous Quality Improve-ment).This requires a framework that defines spe-cific areas of responsibility for providers, primaryhealth care settings, and regional boards. Theseaccountabilities should be jointly developed andsupported by appropriate infrastructure. Theyrequire formal service agreements, periodic reviews,adjustments of expectations, and (re)commitmentto stated goals. Incentives, rewards and standardsfor engaging in quality health promotion practicesshould be integrated into everyday activities. Theaccreditation and valuing of health promotion workremains a key issue.

Governance and decision makingAccountability is achieved by establishing formal

responsibility for health promotion within manage-ment and a working group or steering committee,and by establishing community (client) advisorycommittees or a community board of directors.Incorporating health promotion action into per-formance and accreditation agreements, job descrip-tions and staff performance appraisals at all levelsof the agency also improves responsibility for healthpromotion.

Communication channelsWhile a highly technological health system will

not lead to a general improvement in the well-beingof communities, information systems can enhancecoordination and ensure availability and use of per-tinent client information. A common client infor-mation system also assists in assessing service impactor programme effectiveness, including health statusand population health.A strategy to regularly informhealth professionals of the range and location ofavailable/appropriate health promotion services isnecessary. Finally, health promotion recognizes thatinformation and technology impact differently ondifferent sectors of society.



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Multidisciplinary teamsNo single practitioner or type of practitioner

can meet an individual’s health needs completely.Health promotion requires a shift from a providerfocus, where responsibilities are distinct and sep-arate, to a client focus, where an integrated, multi-service team of providers and professionals (withinand beyond the health sector) work together toaddress needs.The increasing number of practition-ers and their changing roles increases risk of frag-mentation of care. Wider expertise is necessary,and a better understanding and flexibility of rolesand responsibilities is paramount.

Team building should be a deliberate and ongoingactivity to foster collegial interdisciplinary relation-ships (blurring of professional boundaries) or multi-disciplinary teams (involving different professionalswho maintain their professional boundaries).Organizational structures should be developed inrelation to functional groups or programmes ratherthan based on disciplines (Pearson and Jones, 1994).Health promotion competencies are more diffuseand eclectic than the more technical/definable com-petencies used by occupations such as nursing andpharmacy (Keleher, 2001). Developing a commonlanguage and sharing of information and expertiserequires mentoring, workforce development, dedi-cated case conference time, and regular meetings.

An effective multi/interdisciplinary team alsodepends on recruiting individuals with the right mixof skills and knowledge, and the right personalities –those that show a willingness to collaborate, a dedication to the service delivery model and toprinciples of health promotion (Alberta Health andWellness, 2001). Provider satisfaction centres onrole recognition (by themselves and others) andtheir experiences in the collective (Alberta Healthand Wellness, 2001). In smaller teams (of 12 orless), members know each other, are aware of andvalue each other’s skills and interests, and share insetting and achieving goals (Pearson and Jones,1994).

A minimization of professional dominanceensures that no one group or individual is accordedor takes on a dominant role.At the same time, phys-icians who are part of a multidisciplinary team thatemploys a health promotion approach (or are devel-oping new service delivery models) must activelyparticipate in broad planning and development at the community and policy level (Nova ScotiaDepartment of Health, 2001).

Organizational cultureAlthough not a tangible structure, an organiza-

tional environment conducive to health promotionstresses change, learning and personal growth in atransparent and collaborative manner. Althoughpartnerships and grassroots support are imperative,successful settings focus on internal integrationbefore attempting to encompass partners outsidethe organization.

Discussion

To improve the health status in developing anddeveloped countries, a revitalization of the tenetsand values of the Ottawa Charter and the Alma-AtaDeclaration is needed. Commensurate structuresmust also be refined and/or developed to provide the‘building blocks’ for a health promotion approach.This places renewed emphasis on developinglocally defined, primary health care models thatare both flexible and adaptable.

There is a clear divide between the concepts of‘health promotion’ and ‘primary health care’ andtheir implementation since these concepts have notmaterialized into joint, widespread practical action.This is due in part to a lack of understanding of theintricacies inherent in the definitions. There is alsoconsiderable confusion in current health servicemodels about the causation of ill health, the import-ance of the determinants of health and their requisite translation into intervention strategies.Marshall and Craft (2000) assert, ‘much of this con-fusion arises from the peddling of simple concep-tualizations of complex phenomena’ (p. 43). Healthpromotion and primary health care are often conceptualized in a simplistic manner, when in factthey are both complex and sophisticated philoso-phies which have corresponding practical actions toattain improved health outcomes. Both the termsprimary health care and health promotion areunderstood very differently by many stakeholderswhich is why a clear elaboration of the terms, andtheir inherent values and structures, is warranted.These values and structures serve as a catalyst andfoundation for HP in PHC.

Both ‘primary care’ and ‘primary health care’refer to the first level of contact people have withthe health care system. Conventional primary care(or selective primary health care as it is sometimesreferred to as) is individually focused on the person



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seeking care. Such care does not take into consid-eration the distribution of health problems in thecommunity, or the underlying causes of illness anddisease. Most primary care interventions are limitedto the most basic provision of curative and prevent-ive services, which are reactive, episodic and brief,and thus health promotion interventions tend tobe clinical in nature, such as advice giving. Healthpromotion in primary (medical) care is reduced to a biomedical and disease focus. As such, theindividual is targeted for change rather than thesocial and environmental conditions that underliethe disease or condition.This conventional or select-ive approach to primary care is inadequate forintervening in health problems that have socio-environmental root causes, and reducing healthdisparities. Results of biomedical, lifestyle healthpromotion initiatives are often unimpressive andyield only small gains at the individual level.

If primary health care is disguised as primarycare, it will loose its significance. Often the term‘primary health care’ is used without any reorien-tation of services as a way of legitimizing servicedelivery, however, primary health care is more com-prehensive than primary care. Primary health careis an approach concerned with health promotionand population health. Primary health care is popu-lation focused and understands individuals fromthe broader context and links interrelated healthdeterminants to health outcomes. Primary healthcare is proactive, and demonstrates a commitmentto causal circumstances of the presenting problems.A health promotion approach in primary healthcare requires a reorientation of health services thataddresses downstream problems and upstreamhealth issues, dealing with health and its mainten-ance as well as disease and its treatment. A healthpromotion approach in primary health care per-tains to both the individual and the population ofindividuals. It requires a comprehensive approachemploying multiple strategies to have substantialchange. Health promotion pays attention to thesocial, economic and political factors that influ-ence a population’s health. A health promotionapproach would also address the ‘inverse care law’given that needs and demands are clearly divergentwith those in greatest need of a given interventionthe least likely to avail themselves of it.

Uniting health promotion and primary healthcare in a common conceptual framework strength-ens each paradigm and has the potential to improve

the health status of the population and reduce healthdisparities. Since the Ottawa Charter of HealthPromotion (WHO, 1986) and the Declaration ofAlma-Ata (WHO, 1978), much of the literatureand debate has remained as isolated componentsof categorical disease prevention and manage-ment interventions. To this day, there is a lack ofconsensus regarding a formal, consistent and inte-grated approach of health promotion in reorient-ing health care service. Little progress has beenattained in defining an explicit, detailed and com-monly agreed upon framework for implementingchanges in a systematic fashion (Lopez-Acuña et al.,2000). The current research provides a HP in PHCframework to support practical and attainable actionin policy, practice and research.

An obvious starting point is the creation of a vision that makes these values and structuresexplicit. A broad/inclusive definition of health promotion, and a commensurate vision must beplanned and agreed upon by everyone from theboard and executive level to the front line prac-titioners and the community at large. Without aclear mandate for health promotion, it tends toremain at the periphery of service delivery, andprogrammes tend to be ad hoc, issue based andbased on health education, alone. This fragmentedapproach serves to maintain the marginalizationof health promotion.

Through the visioning process, stakeholders mayinteract with one another to negotiate a new set ofshared norms, informal/formal rules of behaviour,develop a sense of ownership and a common bondof the problems to be solved even among the mostdiverse participants (Alberta Health and Wellness,2001). The vision becomes a framework for actionand describes what health promotion will look likewhen the vision is implemented. As stakeholdersand community needs change, a vision must berefined and regularly communicated. The overallgoal is to improve the health of individuals and thecommunity by improving the quality/quantity ofhealth promotion that occurs in primary healthcare settings. The philosophy and mission of thesetting must be compatible with partner agenciesto ensure true collaboration over time.

In order to achieve a health promotion approachin primary health care, stakeholders (such as policymakers, practitioners, researchers, citizens) mustreflect on the values of health promotion, anddevelop commensurate structures. The proposed



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framework is comprehensive in nature because itrecognizes that multiple stakeholders are respon-sible for promoting the health, and it should not besimply delegated to physicians or reduced to healtheducation. Efforts at HP in PHC have not been‘wrong’ per se, but rather are superficial and fallshort, and thus are unlikely to have a substantialeffect on population health.

Conclusion

Increasing the orientation of primary care servicestowards a health promotion approach will bringconventional primary care closer to primary healthcare as envisaged by the Alma-Ata Declaration.Wehave argued that for health promotion to come tofruition in a primary health care setting it must havea solid foundation. This foundation comprises keyphilosophical values and related structures that cre-ate a supportive environment for health promotioninitiatives. These values and structures must beimplemented on a sustained and comprehensivebasis.

This article represents the first of a series of two(see Moulton et al., 2006) articles that present aframework of HP in PHC. The framework has fivedomains (values, structures, strategies, processes,and outcomes). Moulton et al. (2006) present thecorresponding strategies, processes and outcomesthat build upon the present values and structures.

Acknowledgements

The authors wish to thank the Health ReformWorking Group of the Canadian Consortium forHealth Promotion Research, their coinvestigators,advisory committee, focus group participants, andothers who contributed to this work.The work wasmade possible by a grant from the CanadianInstitutes of Health Research.

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