Urbanisation, inequalities and public health

Nowadays, people in Europe live longer and lead healthier lifestyles than ever before. However this does not give grounds for complacency. One in five citizens still dies at early age, often due to preventable disease, and there are disturbing inequalities in health status between social classes and across geographical areas. Urbanisation is an on-going process, having a profound impact on people’s livelihood and health status. The globalisation of markets, increased use of communication and new information technologies are the driving forces behind this process. The urbanisation process has marked effects on the natural and cultural environment, on housing arrangements and social networks, as well as on work and employment patterns, not only in cities, but also in rural areas. Urbanisation seems to lead to greater inequalities among population groups in regard to distribution of risk factors to health, both within the urban areas as well as due to rural-urban differences. Access to health care, social services and cultural activities are generally often better in the cities, but usually access is not evenly distributed among the population.

Salutogenesis as a supplement to pathogenesis

These rapid processes of change represent a challenge to public health policy. Public health research and practice should focus not only on factors causing disease and injuries (pathogenesis), but also factors promoting health (salutogenesis) in the perspective of health promotion and prevention in different settings. Tomorrow’s society will most probably focus more on that which strengthens health, namely the salutogenic (health causing) factors as described by Antonovsky (3). The shaping of health promoting settings at work, in hospitals, in schools and in local communities, therefore has been significantly supported by the World Health Organisation (WHO).

Partnerships for public health

Health promotion requires partnerships for health and social development between the different sectors at all levels of the community (4). Existing partnerships need to be strengthened and the potential for new partnerships must be explored and evaluated. Partnerships are now used as a public health tool in some European countries. Two cases from United Kingdom and Norway are examples of this kind of community approach to public health.

The first example is the introduction of partnership in East Anglia, England (5). The Joint Plan for Colchester, June 2004, will improve the healthand wellbeing of local people, particularly those who are experiencing poor health linked to social and economic deprivation or other forms of disadvantage.

Underlying the plan are three main principles:

• 1. Reducing health inequalities

• 2. Social, cultural, economic and environmental factors have not only direct impact on health, but may also limit or strongly influence the choices people make about their lifestyles and behaviours.

• 3. Significant improvements in public health will only occur if organisations work together towards shared objectives.

There are already many local groups, involving a wide range of agencies working together, that focus on public health issues. What has been missing is an overarching cohesive, coordinating group to ensure that there is progress in all relevant areas with clear links across groups. The overarching group will also ensure that duplication of effort is minimised. It is planned that the Colchester Partnership for Public Health Group will take on this role (5).

Increased community capacity and empowerment to the individuals

Health promotion is carried out by and with people, not on or to people (4). It improves both the ability of individuals to take action, and the capacity of groups, organisations or communities to influence the determinants of health.

«Settings for health» represent the organisational base of the infrastructure required for health promotion (4). New health challenges mean that new and diverse networks need to be created to achieve intersectoral collaboration. Such networks should provide mutual assistance within and between countries and facilitate exchange of information on which strategies are effective in which settings.

Experience with a new community based approach to health promotion in Norway

The second example is from a municipality west of Oslo. Partnerships for health promotion and new and diverse networks have been created to achieve intersectoral collaboration in a local community (6). The aim was to create a common arena and forum for wholeness thinking and creativity, in order to improve environment, quality of life and health among people in the local community (7). The challenge was to get various interest groups, i.e. public agencies, private businesses, voluntary organisations andpioneers to co-operate in order to develop the idea to be realised in health promoting settings (8). The centre described below is now one of the official partners of public health in the county of Akershus as well as the municipality of Asker.

At the Centre for Nature-Culture-Health (NaCuHeal) in Asker there have since 1994 been several experiments where individuals from the local population have been helped to find their own talents and capacity for work to maintain function and pleasure in work (6–8). At the Nature-Culture- Health centre it is desirable with participation and positive interactions between persons of all ages, health status, philosophies and social positions. The idea is that such a meeting place between practitioners and theorists, between the presently well and the presently not so well, will be stimulating and enlightening to most people. Through participation in Nature-Culture-Health groups the individual will find the opportunity to bring to life his or her own ideas by emphasizing positive and creative activities outside one self. At the same time, NaCuHeal-activities may nourish other sides of one’s personality that may also need development, attention and strengthening, to prepare for community and new social networks.

Persons with different health problems may forget their health related and social problems for a while. Among others, some participants were long-term certified sick, in rehabilitation or other social security clients.

The NaCuHeal concept

The concept of Nature-Culture-Health is based on the idea of stimulating to wholeness thinking and creativity by emphasizing:

• Nature, out-door life, and environmental activities

• Culture, art, physical activity and diet

• Health promotion, prevention and rehabilitation

The intention was to:

• Increase participants’ own empowerment and participation in activities in relation to strengthening their own health, quality of life and function

• Create growth in social networks that are encouraging and stimulating

• Motivate to work ability and to explore ways of coping in day-to-day activities.

The activities seem to strengthen the ability to cope, improve quality of life and enable us to meet everyday life in a positive manner. To encourage NatureCulture-Health activities among other things means emphasizing the positive factors leading to health (salutogenesis). Health may in this context be defined as having as little illness as possible while having the energy to cope with the tasks and challenges of everyday life.

Many individuals have through different Nature-Culture-Health activities experienced that e.g. dance, music, art, physical activity, nature walks, hiking, gardening or contact with pets give an indirect effect with feelings of zest for life, inspiration and desire for rehabilitation. For many persons certified sick, this has been a method for return-to-work. The direct route through vocational rehabilitation may be of help to some people. For others, however, it may be necessary to take a more indirect and creative route to succeed in their rehabilitation, i.e. to practice and participate in NaCuHeal-activities for later to achieve a more useful and active existence. The way through such creative activities may give each individual a feeling of meaning and desire to act.

There is reason to believe that there is an untapped potential for improving public health by employing health-promoting nature and cultural activities. This is also a great challenge to our new multicultural and urban society. The goal is increased ability to cope, productivity and prosperity to all people, i.e. not only the affluent members of society, but also the ones who are in danger of becoming permanently incapable of working.

The challenge is to get various interest groups, i.e. public agencies, private businesses, voluntary organisations and pioneers to co-operate in order to develop this idea to be realised in health promoting settings.

New challenges for public health evaluation and information

Since new health challenges mean that new and diverse networks need to be created to achieve intersectoral collaboration, new methods of public health research have to be developed. Synthetic research methods probably have to be applied in order to evaluate the community approach to public health used at the NaCuHeal-centre in Asker.

The increase of information and publications of science, medicine, public health and health promotion force us to develop new information systems in order to apply an evidence based community approach to public health in the years to come. Information design and Polyscopic Modeling offers a way to construct reliable or scientific high-level information (9). The potential for a more holistic community approach to public health practice and policy, underline the importance of interdisciplinary collaboration in our future research (10).

The Norwegian Society of Public Health (NFSH) is a new interdisciplinary organisation promoting public health through research, training, policy development and practice. The focus is on lifestyle, healthy environment and alleviating inequalities in health. NFSH is a member of the European Public Health Association (EUPHA) (11); and the World Federation of Public Health Associations (WFPHA).