Keynote speeches: Abstracts/executive summaries

It is now well recognised that promoting social justice through tackling health inequalities is our major public health challenge. Health promotion can make a significant contribution to reducing health inequalities, but to do so it requires health promotion researchers and practitioners to shift their gaze upstream from the individual to focus upon how to influence the social, economic, environmental and political contexts in which peoples behaviour is shaped, enacted, experienced and understood.

Individually focused interventions based on psychological models of behaviour change involving counselling, reinforcement, information, personal skills development, reflection and coping strategies, do work in a modest way. But mostly for those with more financial resources, the better motivated and better educated members of societies. Health promotion seems to work best for all when it not only supports and promotes individual efforts, but when it also capitalises upon and enhances the value of social support, relationships, partnerships, formal and informal networks, for the exchange of ideas, information, practical help, resources and access to services. Volunteer work, peer programmes and local participation through social action committees ensure the maximum benefit from such community based approaches. The greater the level of local community involvement in setting agendas for action and in sharing power and control over everyday activities, the larger the health promoting impact to be gained.

Such evidence does raise key challenges for research in health promotion as we move into the next century.

There is an imbalance in power and control over health, quality of life and life outcomes between poorer individuals, the people who represent them and the institutions which serve them. This includes control over health environments, power to influence structures and systems, greater democracy in terms of action of access to services and information, policy decision-making through participation. Health promotion needs, therefore, to develop more sophisticated population-based theoretical models of positive health experience. Scholars have alluded to this requirement for years. Recently progress has been made in applying theories from political science and economics to health promotion. The notion of social capital, for example, as a means of building social trust and cohesiveness and reducing inequalities, is one such construct which this paper will discuss.

Adoption of a broader view of the prospects and possibilities of health promotion should allow us to re-visit and re-analyse existing data sets with a fresh eye. This in turn may lead to an enhanced understanding of why inequalities and variability in health experience exist. It may offer up new hypothesis for testing and significantly enlarge the evidence base for health promotion. Examples of this approach will be presented.

Health promotion interventions that aim to have an impact upon the health of populations and communities will require the development of new indicators to allow us to measure their benefits. This is a major research task and this paper will describe recent attempts.

Whilst other disciplines such as medicine may cleave desperately to their restricted disciplinary boundaries, health promotion is well placed to make the necessary leap across conceptual, professional and lay barriers to allow its research to inform policy and practice and contribute to change. How to do so with confidence and credibility provides the final question to be addressed by this paper.

challenges facing Europe together with their root causes and, second, an examination of the current policy environment to assess how best it might be influenced.

In policy terms, there is a need to refocus "upstream" to the wider determinants of health in the social and economic policy environment and how these might be addressed. In today's Europe focusing upstream poses new research questions which this presentation sets out to explore.

In the first section a conceptual discussion and analysis of Evidence Based (EB) Health Promotion (HP) takes place.

The basic idea of an EB approach is sound. However, one has to remember that the EB approach has its roots in the medical treatment sector and in medical research. Later the idea has diffused to the field of HP and to Health Policy. EB Health Policy is now a concept being discussed in international scientific journals.

One cannot directly transfer ideas of research and of systematic reviews related to rather narrow, technical, treatment interventions to the broad field of HP and Public Health. Broader social and societal interventions need special considerations.

The EB approach is basically a strengthening of scientific input to social change and a strengthening of scientific power in society.

Theories of social change acknowledge scientific results and scientific knowledge as one among many other change factors. This has to be remembered when dealing with HP policies, change and development.

The concept of evidence and of scientific evidence is discussed in relation to a rather narrow preventive medical intervention (mammography) and a broader societal situation: unemployment.

The second section of the presentation focus on evaluation of HP trials and Disease Prevention trials. The Health Promotion Research Agenda for the 21^st Century must recognize a varied answer to the question: Which evidence are we looking for? - and when? Methodologic conformity does not give us the wright answers.

Based on the experience that too many evaluators and researchers ask wrong questions at wrong times using wrong methods, an evaluation strategy and terminology is proposed.

The following terms are used:

C. News trials (nyhedsforsög)

C. Demonstration trials (demonstrations forsög)

C. Acceptance trials (accept forsög)

C. Quality Assurance trials (kvalitetssikrings evaluering)

The purpose and methods to be used for appropriate evaluation is explained. (Reference: Finn Kamper-Jörgensen: Evaluering af folkehelsearbejde. Nord Med 1995;110:242-245)

We need a common terminology and a common understanding of a varied approach to EB HP for the next century

At present two current distinct community-oriented health promotion practices are discussed, sometimes representing more biomedical and disease prevention orientation and sometimes more phenomenological and socially critical socio-environmental orientation. In the first instance, community becomes a venue for health behaviour programmes. In the second instance, community becomes a locus for organising efforts to shift broader public and private socio-economic policies and practices. These contrasting perspectives on theory and practise of health promotion could offer an exciting basis for this plenary discussion.

The World Health Organisation (WHO) seeks integration of the two perspectives, and this perspective has eloquent defenders in leaders such as Professor Andrew Tannahill of the Health Education Board for Scotland. It also has eloquent detractors such as Professor Jane Springett at John Moores University in Liverpool.

If Health Promotion is an umbrella concept which includes a more traditional disease prevention and a more health-oriented area, wouldn't we then need another term to describe the health-oriented area? What could that be? Or if we define health promotion only as this health-oriented part, wouldn't we then need a new umbrella concept. In the real life and in practical work these two fields cannot be separated.