Health Promotion principles as a catalyst for translating the SDGs into more transformative action

The Ninth Global Conference on Health Promotion in Shanghai in November 2016 will focus on the role of health promotion in implementing the Sustainable Development Goals (SDGs: UN, 2015). This global forum coincides with the 30th Anniversary of the Ottawa Charter for Health Promotion (WHO, 1986), which has for three decades provided the framework for health promotion research, policy and practice in five key action areas: ‘building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills and reorientating health services towards prevention of illness and promotion of health’. It is thus timely to ask where these action areas (and their subsequent iterations and elaborations from global conferences in Adelaide, Sundsvall, Jakarta, Mexico, Bangkok, Nairobi and Helsinki) fit into the thrust of the SDGs. How might our global calls for action help shape the translation of the SDGs into concrete activities and what synergies can be exploited, and discordances addressed, between the Ottawa Charter (along with its later iterations) and the SDG agenda for 2031? The inclusive process of developing the 17 SDGs (UN, 2015), as a democratic enhancement of the top-down Millennium Development Goal planning procedures (MDGs: UN, 2000), provided an opportunity for creative and imaginative reassessment of health priorities globally. Emphasis on the environment, human rights and gender equity, in the 169 more fine-grained and global targets of the SDGs, expands the more limited MDG focus on eradicating extreme poverty in only middle and low income countries. An enhanced understanding of the parameters of health, to cover the health effects of systematic social inequality emanating from gender, class and race relations, is certainly evident in the expanded list of targets and goals presented in the SDGs and fits well within health promotion discourse. Eradicating global poverty, hunger, corruption, warfare, injustice and illiteracy and minimizing unemployment, environmental pollution and climate change, as primary requisites for optimum universal health and well-being, also meld with health promotion targets. The positive spin on some of the targets such as quality education, clean water and sanitation, affordable and clean energy, decent work, industry innovation and infrastructure, sustainable cities and communities, responsible consumption and production, peace, justice and strong institutions and partnerships to achieve goals could have been written specifically for the Ottawa Charter 30 years ago. However, other areas, most notably Goal 8 on the economic growth targets and Goal 3 on the interpretation of well-being, are more problematic for health promotion researchers and practitioners. Was the window of opportunity to critically reassess currently used indicators of progress, and conventional indicators of health status, missed in the SDG planning process? It appears that the public health and health promotion voices were quite strong in some areas but faint in the consultation process that led to a relatively orthodox set of indicators and targets in SDG 3 and SDG 8. Despite the obvious improvements on the MDGs, especially the globally inclusive consultation process and the move to a truly global focus for action including high income countries, the SDGs have received criticism from many quarters. The Economist in March 2015 referred to the 169 proposed targets as ‘sprawling and misconceived’, characterizing the SDGs as ‘worse than useless’ and a ‘betrayal of the world's poorest people’ (The Economist Group, 2015). Others refer to the goals and targets as vague and aspirational and on a par with ‘a high school wish-list for how to save the world’ [quoted in (Hickel, 2015), p. 1]. The most insightful criticism comes from the anthropologist Jason Hickel who argues that the SDGs ‘aim to save the world without transforming it’ (Hickel, 2015, p. 2). This criticism encapsulates the ‘mortal flaw’ of an underlying contradiction in the SDGs between ‘less and more’. In particular, Hickel refers to the contradiction between environmental concern for less pollution and the emphasis on the ‘old model of industrial growth’, which aims to produce a 7% annual GDP growth in least developed countries and continue high levels of growth in the rest of the world (Hickel, 2015). The version of ‘development’ proposed is designed to take the form of ‘export-oriented growth in line with existing neoliberal models’ of economic advancement. This is a problem for all disciplines, including health promotion, which are critical of the conservative use of GDP as the only indicator of economic and social progress. The charge of attempting to ‘change the world without transforming it’ can also be applied to Goal 3, where the word ‘well-being’ is used in a traditional sense to refer to life expectancy and mortality and morbidity rates rather than positive health. This missed opportunity to transform understandings of both the concept of well-being and measures of progress has been highlighted by commentators from the South as well as the North (Hickel, 2015; Tobgay, 2015). The debates about the post-MDG agenda for 2016–2031 continue to refer to the various sets of internationally agreed indicators of progress. By the turn of the twenty-first century, it had already become obvious that gross domestic product, life expectancy and mortality and morbidity rates were not sufficient indicators of progress in societies across the economic spectrum. The development of subjective well-being indicators, to provide a subjective reflection of progress complementing objective indicators, created an opportunity for countries to recalibrate what the terms progress and well-being really mean. Most notably, Bhutan's move to Gross National Happiness, using a variety of non-economic indicators, provides a template for other nations to emulate. In his opening address to the 2015 International Conference on Gross National Happiness, the Prime Minister of Bhutan highlighted the folly of falling back on traditional ways of measuring progress. Tobgay pointed to the unintended consequences of ‘the mad rush for increasing GDP’ to the point where it came to be seen ‘as a surrogate for societal well-being—something it was never designed to be’ [(Tobgay, 2015), p. 1]. We need to understand that the notion of progress goes well beyond lack of income or consumption to include non-monetary aspects such as weak social connections, the psychological costs of alienation and isolation, the exposure to risks and the experience of vulnerability. We need a clear, coherent and compelling complement to the dominance of GDP. We need a new and transformational approach to defining and measuring wellbeing. Tobgay's critique of the neoliberal economic model is applied specifically to the 17 SDGs, where he argues that the ‘ambitious list’ of SDGs … lacks a coherent and compelling account of wellbeing, and it leaves out our culture, relationships, and even details like balanced work life. The solution clearly lies in changing the very purpose and goal of development. If the basic purpose of development were changed from the pursuit of profit to the pursuit of higher wellbeing in all its dimensions, the true level of happiness on the planet would certainly go up. The Stiglitz Sen Fitoussi Commission stated this. The Beyond GDP initiative in Europe recognizes it. The array of new wellbeing initiatives in measurement and action testify to it. On a global scale, in response to the Stiglitz–Sen–Fitoussi Commission, the Organisation for Economic Co-operation and Development embraced non-economic indicators of progress in its Better Life Index (OECD, 2011) including civic engagement, life satisfaction, safety and work–life balance. Furthermore, the United Nations Development Programme acknowledged the growing ‘interest in using subjective data to measure well-being and human progress and to inform public policy’ [(United Nations Development Programme, 2013), p. 28], and these are increasingly being used to complement traditional and objective measures in the World Development Reports. The eclectic melding of objective and subjective measures of economic, social, political, cultural and personal well-being address both personal and collective challenges. This facilitates the development and application of new tools to gauge levels of well-being and impact of interventions. These in turn can inform policy-makers, service providers and communities generally about remaining gaps in understanding inequalities and challenges including global inequalities in choices and opportunities for disadvantaged and marginalized groups. Despite these insights and major global developments (many of which would have been fed into the debates leading up to the final SDG document by the United Nations Data Revolution Advisory Group), the wording of SDGs 3 and 8 remains conservative. The wording of SDG 3 on promoting well-being starts with a holistic approach to health and well-being but then proceeds to emphasize gains in life expectancy and disease prevention in rhetoric that parallels the ‘lifestyle drift’ argument adopted by many public health campaigns in both high and middle income countries (Baum, 2011). It is predominantly focussed on preventing death and ‘sick-being’ rather than actively promoting positive well-being by maximizing healthy political, social and economic environments. The health and well-being promotion message is seriously diluted in both the review of MDG successes and the listing of remaining challenges. Ensuring healthy lives and promoting the well-being for all at all ages is essential to sustainable development. Significant strides have been made in increasing life expectancy and reducing some of the common killers associated with child and maternal mortality. Major progress has been made on increasing access to clean water and sanitation, reducing malaria, tuberculosis, polio and the spread of HIV/AIDS. However, many more efforts are needed to fully eradicate a wide range of diseases and address many different persistent and emerging health issues. The review of gains between 1990 and 2015, and remaining challenges, is couched in the language of nineteenth and twentieth century public health, epidemiology and health indicators: mortality, morbidity and life expectancy. For example in reference to child health the SDG documents boast: ‘17,000 fewer children die each day than in 1990’ and ‘since 2000, measles vaccines have averted nearly 15.6 million deaths’, but no mention is made of the improvement in the quality of those children's lives. Similarly in naming remaining challenges for child health and well-being, SDG 3 points to premature death but does not address more general aspects of well-being. Exactly the same story, about significant indicators for measuring gains and remaining gaps, prevails for maternal health, HIV/AIDs and malaria. The emphasis is on life expectancy and death rates (representing quantity of life) rather than quality of life. This trend flows into the SDGs. Despite the rhetoric of addressing well-being in the preamble to Goal 3, the goals for the SDGs are no less traditional than those of the MDGs. The targets under the rubric of ‘well-being’ do in places include reference to prevention and promotion of mental health but even here the aim is to prevent death, disease, risk and injury rather than promote positive well-being. Furthermore, medicines and vaccines, rather than structural change and building healthy public policy and social capital, feature dominantly in the recommendations for prevention and health promotion. The papers that appear in this edition of Health Promotion International provide creative challenges from Africa, Europe, Asia, the Americas and Oceania for consideration at the Ninth Global Conference on Health Promotion in Shanghai in November 2016 as the synergies and dissonances between the SDGs and health promotion are thrashed out. The eclectic mix of papers question traditional approaches to theory, measurement, methodology, practice and policy for promoting health and imaginatively experiment with non-conventional actors, technologies and settings for health and well-being enhancement. In addressing health promotion settings, Corburn and Karanja see informal settlements and slum communities in Nairobi, Kenya, as an ideal setting to apply key inter-sectoral health promotion principles, learned from the healthy cities movement, to enhance good sanitation practices, gender equality and personal and community dignity. Dignity is also the theme of Trojan et al.'s research on self-help friendliness in German hospital settings as a key tool to improve patient-centredness and consequently the satisfaction, self-management, coping and health literacy of chronically ill patients. Chu et al. use the home as the setting to examine housing conditions as a key determinant of sleep-related infant injury deaths in the USA, arguing that poverty is the primary upstream contextual contributing factor. The school is the setting chosen by Simovska et al. in Denmark to test the inter-sectoral collaboration across local authorities and schools in relation to synergizing priorities, policies and practices between the educational curriculum and health goals. Peters et al. continue the theme of inter-sectoral public policy, raised by Corburn and Karanja and Simovska et al., in the Dutch context arguing that integration with non-traditional sectors varies according to the health issue under consideration, but that shared information across sectors about determinants of health would enhance the development of effective integrated policies. Risks associated with infectious disease are addressed by Tenkorang in researching gendered understandings of perceived vulnerability and HIV testing among youth in Cape Town and by Marais et al. in stressing the importance of early, active and sustained community engagement, alongside trust, to prevent and control Ebola throughout Africa. The risk focus then moves to chronic diseases such as hypertension and obesity and the problem of lack of physical activity in Guatemala (Montano et al.), Australia (Opal Collective and Caperchione et al.), the Netherlands (Verwey et al.), USA (Yang and James) and six European countries (Aro et al.). Health promotion solutions vary from yoga as a ‘stepping stone’ towards regular exercise (Yang and James) to community-oriented hypertension management programmes (Montano et al.) and upgrade physical activity counselling protocols for chronically ill patients in primary care to include smartphone applications that patients and their care providers in Verwey et al.'s study found far more user friendly. The OPAL collective highlight the importance of developing appropriate skill sets to produce shared clarity between communities and practitioners as part of the Obesity Prevention and Lifestyle Program. The use of interactive web-based technologies to improve physical activity and nutrition is proposed by Caperchione et al., and game simulations and integrating research evidence and physical activity policies are the key recommendations of the research by Aro et al. The risk theme continues in addressing the risky side of youth. Thao and Trieu discuss the feasibility of a mindfulness-based intervention to address the risk temptations of young people in Vietnam. They argue that mindfulness helps reduce stress and build life skills to counter risk-taking around sex and substance abuse. Tobacco risk is the focus of the paper by Ayo-Yusof et al. in Africa. The researchers examine the impact of school personnel's permissiveness towards tobacco industry sponsorship on their support for complete bans on tobacco advertising and suggest that their findings point to the need to educate school staff on the strategies employed by the tobacco industry to get around tobacco control regulations and control policies. The alcohol industry is the target of Jones et al.'s analysis of the impact of alcohol-branded merchandise on alcohol consumption. The researchers suggest the need to raise parents' awareness of this link so that they can reduce their children's exposure to such alcohol marketing. Buhler et al.'s research in Germany proposes further strategies to reduce adolescent alcohol consumption in leisure settings, including peer-led educational prevention measures as part of the German ‘na Toll’ alcohol harm reduction programme. Nwagu's study of student's perception of the influence of alcohol and drug usage on adolescent sexual behaviour in Nigeria found significant class and gender differences and, like Ayo-Yusof et al.'s and Jones et al.'s recommendations, proposes education as a key component of health promotion strategies to reduce both alcohol consumption and risky and abusive sex. Youth and risk is also the theme of Ward et al.'s paper on participatory photography to give voice to young non-drivers in New Zealand. This creative research addresses the high crash injury rate among young Maori, Pacific and Asian drivers and provides an imaginative venue for young people who choose not to drive to make non-driving ‘cool’. Education also provides the framework for the reported research on health literacy in this edition. Eyuboglu and Schultz's validation of Turkish health literacy measures with diabetes patients proved reliable and valid for broader application to increase self-management outcomes for all chronically ill patients and other marginalized groups in Turkish society. Similar aims are evident in Liu et al.'s qualitative research, in USA, UK, Australia, New Zealand and Norway, to adapt health promotion interventions and language so that they are accessible to people from ethnic minority groups. Improving the health literacy of older Serbians through computer and online strategies is the focus of Gazibara et al.'s research and building healthcare workers' ‘literacy’ and comfort levels for working with same sex parented families in Australia is the central aim of van Douss et al.'s paper. Together these papers extend the interpretation of the Ottawa Charter in line with technological, methodological, and developments the 30 They question the as approach to illness prevention and health promotion and the insights they will to the 2016 from the November global health promotion and in turn have an impact on how the SDGs are and reported on in and of the personal skills action of the Ottawa on the of the of the the of health in promoting the of the between the and the public aspects of health and the of health with all other of human and 2011). The Ottawa Charter has provided a template for and commentators from a wide array of to a critique of the application of neoliberal to all of life. years the Ottawa Charter this critical further and of the social, economic and globally. very and support global and to at least upstream social social justice and inclusive in developing policies and is some evidence of this in the SDGs where consultation was far more inclusive than in global and social determinants are clearly out. The Ninth Global Conference on Health Promotion is an ideal venue to the process of all 17 of the SDGs, especially SDG 3 and SDG towards activities that are with the five action areas of the Ottawa

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