The Ottawa Charter for Health Promotion (1986), is regarded as a landmark document in defining the goals and concepts of health promotion, including how public health problems are conceptualized and addressed (Hancock, 2011; Let’s Learn Public Health, 2017; Nutbeam, 2008; Thompson et al., 2017). The Charter aims to reframe health as an issue of systems and environments rather than one of (solely) individual agency (Fry & Zask, 2017; Thompson et al., 2017), and in turn stimulate advocacy, research, and the establishment of an evidence base towards the goal of improved political influence and health for all (World Health Organization [WHO] European Region, 2011).
However, and despite it’s landmark status, many have argued that Charter relevance has declined in recent decades, leading to a weakening of its influence on individual, population, and global health (Woodall & Freeman, 2020). Specifically, a lack of theoretical framework underlying the Charter’s creation is cited as encouraging a watering down of the health promotion movement (Eriksson & Lindstrom, 2008). This, it is argued, has allowed for varied interpretations of Charter aims (at all levels of government), and led to relative inaction in several key areas and the maintenance of a pathogenic approach to health which fails to employ the upstream thinking necessary to teach, enable, and empower the public towards a healthier life (Eriksson & Lindstrom, 2008; Hancock, 2011)
Examining Action Areas
Application and implementation challenges are particularly evident when one examines the Charter’s action areas. Notably, a commitment to reorient health services is an aim many have cited as having little evidence of occurring anywhere in the world (Nutbeam, 2008; Thompson et al., 2017; Woodall & Freeman, 2020). Instead, global acute care spending continues to increase, and health promotion initiatives remain targeted towards individual behaviour change (Fry & Zask, 2017; Thompson et al., 2017), demonstrating the consequences of misinterpretation and “addiction to superior [read: biomedical] knowledge,” (Fry & Zask, 2017; Hancock, 2011; Nutbeam, 2008; WHO European Region, 2011).
Development of personal skills represents another area of contention. To date, many health promotion programs continue to serve as an information dump rather than a dialogue through which participants can gain a better understanding of health and its determinants; The latter serving as a pathway towards recognition and meaningful action (Eriksson & Lindstrom, 2008). Add to this a lack of evaluative guidance (Fry & Zask, 2017), and it is no wonder that Charter support is waning.
Recognizing Bias
Further criticisms of relevance surround evident bias in the Charter’s writing – Most obvious, its focus on Western nations (Woodall & Freeman, 2020). Within the Charter itself it is identified that at time of writing “[d]iscussions focused on the needs in industrialized countries…” (Ottawa Charter for Health Promotion, 1986, p.1). This evident limitation leads to valid criticisms surrounding equal representation and a flawed commitment to “enable” - generating related concerns of feasibility of Charter implementation and progress in developing areas (Nutbeam, 2008). Additionally, it sets an important precedent for the justification of broader exclusion of groups deemed “less than” (lacking perceived importance or influence) and subsequent ability to avoid redressing historic and prevailing power imbalances in health and other decision-making.
Continuing down the path of exclusion, the Charter suggests that actions aimed at enabling people to achieve their fullest health must be “applied equally to both women and men” (Ottawa Charter for Health Promotion, 1986, p.1). While on it’s face a solid sentiment, such a binary statement could be seen as excluding those for whom gender, and/or (sexual) identity may be different and opens the door to continued or increased discrimination within the health system. Semantics? Maybe. But bearing the potential for disastrous (health) consequences for large segments of the global population if left unaddressed.
What Should be Done?
So what should be done? More than three decades later, disagreement persists as to whether the Charter should remain “as is” – an important legacy of health promotion and policy - or be subject to revisions and updates to contemporize it and revitalize its sinking reputation (Woodall & Freeman, 2020). However, and similarly to how some perceive the Charter itself, these discussions seem to be all talk and no action.
Rather than view the document as static and unchangeable, critics (demotivated? hopeless?) may be best served to consider the Charter in a similar (more approachable) vein as Charter pioneer Ilona Kickbusch who regards it as a “living document with deep vision and practical orientation” (as cited in Nutbeam, 2008). This view supports an understanding that ideas in and aims of the Charter are fundamentally sound (Nutbeam, 2008) but that updates are likely necessary if the Charter is to be applied to its full potential (Fry & Zask, 2017). Small-ish steps towards a larger goal.
Redefinition within or refinement of the Charter may serve to provide much needed clarity and specificity for those wishing to push forward its agenda. Notably, clear statement of and commitment to a theoretical framework could aim to foster an improved understanding of the important intersection of individual agency and the complex structural forces which guide behaviour (Woodall & Freeman, 2020). The goal: improved health literacy, leading to empowerment of the global community to (press governments to) address more than individual-level health determinants (Thompson et al., 2017). Updates should also seek to recognize the wealth of knowledge to be gained from developing nations (Nutbeam, 2008) and traditionally marginalized groups. This would serve to remedy past indiscretions through a global commitment to inclusion and provide important context; enhancing the Charter’s global meaning, applicability and achievability, and further stimulating research, the development of a global evidence base, and representative policy, moving us ever closer to the goal of health for all.
Conclusion
More than thirty years in, the Ottawa Charter for Health Promotion remains a highly-regarded document in the field of health promotion. However, a solid foundation and good intentions have proven insufficient when addressing the health needs of an ever-changing global population. It is time to move the Charter forward and undertake important updates to maintain relevance and inspire action. Either that or consider downgrading to a less lofty goal of health for some.
References
Eriksson, M., & Lindstrom, B. (2008). A salutogenic interpretation of the Ottawa Charter. Health Promotion International, 23(2), 190–199. https://doi.org/10.1093/heapro/dan014
Fry, D., & Zask, A. (2016). Applying the Ottawa Charter to inform health promotion programme design. Health Promotion International, 22. https://doi.org/10.1093/heapro/daw022
Hancock, T. (2011). Health promotion in Canada: 25 years of unfulfilled promise. Health Promotion International, 26(2), 263–267. https://doi.org/10.1093/heapro/dar061
Nutbeam, D. (2008). What would the Ottawa Charter look like if it were written today? Critical Public Health, 18(4), 435–441. https://doi.org/10.1080/09581590802551208
Ottawa Charter for Health Promotion, November 21, 1986, https://www.canada.ca/content/dam/phac-aspc/documents/services/health-promotion/population-health/ottawa-charter-health-promotion-international-conference-on-health-promotion/charter.pdf
Let’s Learn Public Health (2017, March 4). Health promotion and the Ottawa Charter – Creating healthier populations [Video]. YouTube. https://www.youtube.com/watch?v=G2quVLcJVBk
Thompson, S. R., Watson, M. C., & Tilford, S. (2017). The Ottawa Charter 30 years on: Still an important standard for health promotion. International Journal of Health Promotion and Education, 56(2), 73–84. https://doi.org/10.1080/14635240.2017.1415765
Woodall, J., & Freeman, C. (2020). Where have we been and where are we going? The state of contemporary health promotion. Health Education Journal, 79(6), 621–632. https://doi.org/10.1177/0017896919899970
World Health Organization European Region (2011, September 11). The journey from Ottawa to Health 2020 [Video]. YouTube. https://www.youtube.com/watch?v=gJ1H2ojwb2Q