Operating from a set of philosophies that focus on overall health, quality of life and well-being, Canada has been a world leader in the field of health promotion: "the process of enabling people to increase control over, and to improve, their health" (World Health Organization 1986). As an alternative to lifestyle- and behaviour-based prevention efforts, health promotion aims to facilitate individual and community empowerment so that all people, both ill and well, are able to achieve a greater sense of control over the many complex factors that affect their health. Effective health promotion and prevention efforts do much more than "establish linkages with community resources relevant to chronic illness care" (Glasgow et al. 2001 79: 589-90), as recommended by the CCM. Instead, effective health promotion follows the lead of the community in addressing its needs and developing strategies to meet those needs.
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Proponents of the CCM have suggested that it can also be used for the prevention of chronic disease. Glasgow et al. (2001) theorize that change will be less costly and more effective if both clinical prevention and management of chronic disease use a similar set of improvement strategies. Their paper concludes that the CCM can be used to direct quality improvement initiatives for clinical preventive services. However, Glasgow and his colleagues acknowledge that the "scope and depth of the community resources and policy-linkage components of the CCM may need to be expanded" (Glasgow et al. 2001 79: 602). This paper proposes a strategy to address this requirement, and, at the same time, to broaden the CCM so that it is applicable to clinical preventive services and to other, broader areas of prevention and to the field of health promotion.
It is the experience of the authors of this paper that the current language of the CCM does not resonate with population health promotion practitioners who make up an integral component of publicly funded health systems. Incorporating the principles of health promotion and the focus on the determinants of health as directed by a population health approach enables the CCM to be used by the entire health team in an integrated fashion.
This article examines: (a) the challenges to the current CCM, (b) the evidence for population health promotion and (c) a proposal to expand the existing CCM to include elements of population health promotion.
The gradient nature of health status suggests that it is embedded in collective factors in society, not just in individual factors (Wilkinson 1996). Recognizing the fact that health is significantly affected by policy decisions in non-healthcare areas (including housing, transportation and food distribution), the World Health Organization (WHO) called for inter-sectoral collaboration efforts to improve the conditions required for an optimal level of health and well-being. The result was the (World Health Organization 1986), a document that has radically re-shaped health education and health promotion in many countries around the world. The Charter emphasizes societal change rather than individual responsibility, and supports an active role for the public in setting priorities, making decisions, planning strategies and implementing them to achieve better community health (Terris 1992). It also extends the concept of health to mean a "resource for everyday life" embodying social, environmental and personal assets and physical capacities (World Health Organization 1986). Using this broad definition, enhancing health goes far beyond how much or what type of service is provided as part of traditional healthcare services.
In the report titled (Lalonde 1974), the Government of Canada publicly acknowledged that medicine and the traditional healthcare system play only a small role in determining health status. Instead, health is portrayed as being determined by the interplay of factors, including human biology, the environment and lifestyle. The lifestyle component of the report received the most attention, and efforts were directed to promote the adoption of healthier lifestyles. Canadian programming during the 1970s had a positive impact in terms of smoking (Ferrence 1989), the promotion of healthy eating habits (Labonte and Penfold 1981) and the awareness of the importance of physical activity (Cunningham 1992). However, the approach was criticized for assigning blame to individuals for their own health problems. If ill health was "caused" by poor judgement and decision-making around smoking, nutrition and physical activity patterns, then it is easy to see how individuals could feel judged by campaigns and programming that focused entirely on individual responsibility for behaviour change. There is now a growing recognition that lifestyle behaviours, such as physical activity and smoking, are influenced not only by individual choice, but also by a variety of social, economic and cultural factors inherent in the environments where people live, learn, work and play.
Instead, the influence of the social, economic and cultural determinants of health suggests the need for a comprehensive and collaborative approach to improving health that addresses root causes and tries to avert illness and injury before they occur. "Population health promotion" (Hamilton and Bhatti 1996) is becoming a common way to integrate the evidence of the broader determinants of health (the population health approach) with the actions of health promotion. These actions can and should be implemented at a variety of levels and sectors for them to have maximum effect. Much of the work to improve these conditions falls under the mandate of sectors outside of the traditional healthcare system, including education, justice, housing, employment and others. While the healthcare sector cannot undertake this agenda alone, it can initiate dialogue and act as a collaborator in efforts to improve the well-being of members of the population, especially with those groups that are experiencing poor health. High-quality healthcare services must be supported by policies and programs in communities that allow people time and opportunity to care for each other, without compromising their own health or financial security. The intended outcomes of population health promotion, therefore, include supported institutional, social and physical environments as well as enhanced individual and community capacities.
A population health promotion approach works to improve the underlying conditions of people's lives that enable them to be healthy. As well, it aims to reduce inequities in those conditions that place some members of the community at a disadvantage for maintaining optimal health. Population health promotion includes a variety of approaches to reach these goals. Through the proactive identification of risk behaviours and environmental conditions of client and population groups, population health promotion works to prevent problems before they occur and to avoid further problems from occurring after injury or illness is already present. The ideal result is an enhanced sense of health and quality of life for individuals and families in that community.
The North Karelia Project, a community-based health promotion program in Finland to reduce cardiovascular disorders, has demonstrated the potential of effective population health promotion at work. The project has reported both cost-benefit and cost-effective analysis for its successful heart health interventions in 1972 (onset) and again in 1992. After 20 years, the cardiovascular disease mortality rate in men declined by 68%, while coronary heart disease mortality in men declined by 73% (Puska et al. 1998). During the same period, Finland experienced a US$600 million decrease in its overall cardiovascular-related social cost for those aged 35 to 64 years (Puska et al. 1995).