By Lee, Albert Fu, Hua; Chenyi, Ji
Abstract: China has the world’s largest population. In the past, the public health system in mainland China has been strongly influenced by the former Soviet Union. Hong Kong and Macao, the Special Administrative Regions (SAR), have been under colonial administration adopting a laisser-faire approach to health policy. Over the most recent decades, mainland China and the two SARs have adopted the Ottawa Charter principles and re-orientated the healthcare systems towards greater community participation, built a healthy environment in different settings and developed capacity in health promotion. Positive results have resulted from efforts to move towards a bottom-up approach to health promotion, using the overarching framework of Healthy Settings. Adequate resources will be needed to build up the infrastructure for sustainable development of health promotion initiatives. This report is selective, rather than comprehensive and will highlight specific health promotion activities in different parts of China, reflecting how the approach to health promotion has evolved since Ottawa. An analysis will be made of the potentials of these initiatives to take forward the spirit of the Ottawa Charter in paving the way for the Bangkok Charter. (Promotion & Education, 2007, XIV (4): pp 219-223)
Key Words: healthy settings, capacity building, Bangkok Charter, bottom-up approach
KEY POINTS
* China has the world’s largest population.
* Over the last two decades, mainland China, Hong Kong and Macao have adopted the Ottawa Charter principles.
* Health promotion efforts have been directed towards greater community participation, building healthy environments in different settings and developing workforce capacity.
* Adequate resources will be needed to sustain the infrastructure for health promotion.
China has an overall population exceeding 1.3 billion, containing 56 ethnic groups. There are a total of four municipalities, 22 provinces, five autonomous regions and two special administrative regions, Hong Kong and Macau. Whilst Taiwan is also part of the sacred territory of China, Taiwan will not be dealt with in this report The whole nation will be divided into mainland China, the Hong Kong Special Administrative Region (Hong Kong SAR) and Macao Special Administrative Region (Macao SAR), as the two Special Administrative Regions have separate system of governance under the concept of One Country, Two Systems.
Mainland China
In 2005, the China Human Development Report pointed to radical health improvements generated by economic and social progress. GDP per annum growth since the late 1970s has helped to lift several hundred million people out of absolute poverty and in the past three decades, the life expectancy of the Chinese population increased by nearly eight years. However, China is facing ongoing and emerging challenges related to its continued rapid expansion, income inequality, economically lagging western and northeast regions, unsustainable resource exploitation, and issues related to growing regional and global economic integration. People in the geographically disadvantaged regions migrate to the urban areas, resulting in the rise of urban poverty and growing social discontent. To close the gap and to catch up with mainland China’s wealthier eastern provinces, the government has initiated a number of social welfare projects. Environmental initiatives are also in place to deal with serious degradation as a result of earlier growth at all cost policies.
Demographics in mainland China are changing due to an ageing population, which alongside a decrease in infectious disease rates, are changing morbidity and mortality patterns. Cardiovascular diseases, cancer and chronic respiratory diseases are ranked as the top three of the mortalities and accounted for over 70 percent of total mortality. The prevalence of related risk factors: smoking, physical inactivity, hypertension, hyperlipidemia, and obesity are rising. In 2002 the smoking rate was 66 percent in males; the prevalence of physical activity (more than three times per week) was less than one third; the prevalence of hypertension was 18.8 percent; the prevalence of hyperlipidemia was 18.6 percent; the prevalence of overweight and obesity were 22.8 percent and 7.1 percent respectively.
Hong Kong SAR
Hong Kong has a population about 6.88 million and became a Special Administrative Region (SAR) of the People’s Republic of China on July 1,1997, after a century and a half of British administration. Under Hong Kong’s constitutional document, the Basic Law, the SAR enjoys a high degree of autonomy with a Government known for its efficiency, transparency and fairness. Hong Kong’s health indices compare favourably with developed countries. Health problems are mostly associated with lifestyles-related chronic degenerative diseases such as cancers, heart diseases and cerebrovascular diseases accounting for over 60 percent of all deaths.
Macao SAR
The Government of the People’s Republic of China resumed exercising sovereignty over Macao on 20th December, 1999 after four hundred years of Portuguese administration.
Macao’s population is around 435,000, comprising 51.7 percent female; 15.6 percent of residents are under 15 years of age; 76.1 percent are aged between 15 and 64 and 8.3 percent aged 65 years and over. According to the Statistics and Census Service, in 2005 the general mortality rate was 3.4 per 1,000 residents, while the mortality rate for infants under one year old was 3.3 per 1,000 live births. The average life expectancy was 79.3 years.
Health promotion policy
Mainland China: In the early 1950s, the main policy driver was health propaganda emphasizing prevention of communicable diseases and basic hygiene. During the 1960s, the health propaganda activities declined because of the Cultural Revolution. In the 1970s, health policy momentum emphasised health education, networking, training of professionals and development of settings and population approach to promote health. From late 1980s onwards, the policy directive moved away from the health propaganda approach to an education for health approach. In 1984 the Chinese Health Education Association was established and by 1986, there were Institutes of Health Education at different levels in 26 provinces and over 150 cities.
From mid 1980s to early 1990s, health education was put on the health agenda for health departments at national, provincial, cities and counties levels, with guidelines issued. Appropriate infrastructure was established at different levels to ensure better co-ordination and provide adequate support and resources.
From the 1990s, the hygienic city program, embracing health education and health promotion, has become an integral part of city development. Healthy Cities followed in 1996. The State Council also approved the School Health Act in 1990, containing statutory requirement and guidelines for teaching health education in primary and secondary schools. In 1998 a random survey of schools from 32 cities revealed that over 90 percent of schools fulfilled the requirements of school health education and nearly 90 percent of students had acquired basic health knowledge.
Hong Kong SAR: Statutory measures are established to safeguard and protect the health of the population in terms of infectious disease control, occupational safety and health, smoke free environment, food and industrial safety. The government has created statutory bodies such as Occupation Safety and Safe Council, AIDs Foundation, Action Committee Against Narcotics (ACAN), Council on Smoking and Health (COSH) to help oversee different aspects of population heath. The Centre for Health Protection within the Department of Health was launched in 2004 to strengthen health protection and disease prevention. More recently the Department of Health has established a Steering Committee on Healthy Eating with involvement of academic institutions, professional bodies, non- government organizations, School Councils and Parents’Associations to promote healthy eating amongst school children.
Macao SAR: With rapid globalization and urbanization, policies and strategies are being developed that embrace intersectoral collaboration to safeguard population health. Macao Healthy City has formulated interventions targeting multiple health risk behaviours in different key settings such as schools and workplace, with Health Promoting Schools seen as a key component of the Healthy Cities project.
Health promotion services
Mainland China: The publication of health education periodicals and films resumed in 1970 following the Cultural Revolution. Training of health promotion professionals developed rapidly in many cities and provinces. From late 1970s, health education was introduced in primary and secondary schools in different provinces. The topics ranged from prevention of communicable diseases to healthy lifestyle, including healthy eating. During the 1980s, the academic discipline of health education was introduced at universities. Academic exchange had taken place nationally and internationally including attending and hosting international conferences.
From the 1990s onwards, health education materials had become more scientific and marketable. Health education and health promotion activities emphasized inter-personal communication, peer education, and self-directed learning. The advancement of the theory of health promotion, community diagnosis, mobilisation of community resources, and policies on promoting health has facilitated the development of methods of health promotion. Websites by government or Institute of Health Education have now been established (see, for example www.health-education.gov.cn, www.cnhei.com, www.che.medchina.net).
Hong Kong SAR: There have been many types of services operated at both governmental and non-governmental level for health promotion. Over the last few years, the concept of Health Promoting School (HPS) has been implemented to improve the health literacy of students. The emphasis of public health action has shifted from addressing the devastating effects of the living and working conditions imposed on the population to modification of health risk behaviours by individuals. Schools are regarded as essential in helping students to achieve health literacy.
The Centre for Health Education and Health Promotion of the Chinese University of Hong Kong (CUHK) first launched the HPS Programme in 1998 to provide a good example of close partnerships between health and education sectors, and promotes multi- disciplinary approach and active learning towards health promotion (Lee at al, 2003a). The Centre has trained up large numbers of teachers to adopt a holistic approach to health and supported the integration of school programmes with community resources. The Healthy Schools Award Scheme (HKHSA) has built on HPS (Lee, 2002) and is modelled on the WHO Western Pacific Regional Office HPS framework covering six key areas (health policy, physical and social environments, community relationships, personal health skills and health services). During the SARS (Severe Acute Respiratory Syndrome) crisis, the HKHSA scheme was able to empower schools to step up public health measures against SARS (Lee et al., 2003b).
Macao SAR: To realise the objective of Health for All advocated by the World Health Organization, the Health Bureau has established Health Centres throughout the territory as the operational units for providing comprehensive primary healthcare. Training has been provided for health and education professionals to implement HPS and offer different types of health promotion activities.
Health promotion funding and availability of resources
Mainland China: Since the establishment of People’s Republic of China in 1949, attempts had been made to redistribute healthcare resources to avoid an elite urban physician-orientated medical establishment by placing more emphasis on rural areas (Henderson & Cohen, 1982). With the introduction of advanced medical technology, the financial burden on health was escalating, so means to decrease healthcare costs included avoiding hospitalization whenever possible and controlling the drug cost This has lead to the development of community health services with strong focus on primary care. In 1997, the State Council launched healthcare reform with an integrated approach adopted to manage and prevent non-communicable diseases. It is aiming to develop a strong team of well trained high quality primary care physicians in delivering community health services through curative, preventive and rehabilitative services. In 2001, out of the total of 36 provinces, autonomous regions, municipalities, 15 put the task of health education under primary healthcare and maternal and child health centres. In 13 provinces, autonomous regions and municipalities, health education was put under Centre for Disease Control.
Since 1998, the Community Health Services have developed rapidly. Under the leadership of local government and health education agencies, the community doctors and nurses have been trained to become community health educators. There are also new health insurance policies for people living in rural areas (Liu, 2004).
In order to strengthen health promotion, many provinces and cities had started developing school health education; community based health education for chronic illnesses, promotion of elderly health, and prevention of non-communicable diseases, and are moving away from information giving to a population health approach. During the period 1997 to 2,000 a technical assistance project was implemented in seven cities and one province in China to build capacity for community based health promotion particularly, focussing on the development and management of community health programmes and comprehensive health promotion strategies (Tang et al., 2005). At the same time there was a shift from risk factor orientation to a setting approach and a move away from expert lead approach to a more participatory and problem based approach.
Hong Kong SAR: A Working Party on Primary Healthcare in 1990 recommended a District Health System, a shift to community based healthcare with more emphasis on preventative medicine and the establishment of Primary Healthcare Authority. However, the Hospital Authority was established in 1991 integrating all the hospital services, so the progress of primary healthcare has not been accorded high priority. Healthcare Promotion Fund has been established to fund proposal for pilot health promotion projects, but does not fund research or the furtherance of pilot projects. The AIDS Trust Fund is available for health promotion related to HIV/ AIDs prevention and ACAN provides funding for drug education programmes. There are statutory bodies providing funding for health promotion programmes usually focusing on specific health issues. CUHK, for example, obtained funding from Quality Education Fund (QEF) for various HPS programmes. There is a strong need to have a foundation that would provide health promotion funds for large scale health promotion projects.
Macao SAR: The government maintains its commitment to improving medical and healthcare quality and safeguarding the health of the public (http://www.gov.mo/ egi/Portal/index.jsp accessed August 2007). Medical and health services providers are classified as Governmental or Non-governmental. The former includes Government Health Centres providing primary healthcare and a hospital providing specialists medical services. The latter includes medical entities subsidised by the Government and other institutions. Most medical services provided by the Government are free.
Community participation in health
Mainland China: A number of initiatives have encouraged community participation. In 1986, the Ministry of Health together with Broadcasting Authority started First Special Award for films and television programmes related to health, to encourage participation from different sectors. There was an early adoption of WHO participatory approaches, with Healthy Schools introduced 1995, two Healthy Workplace demonstrations sites developed in Shanghai (WHO, 1999) and Healthy Cities piloted in six cities in 1997. The Alliance for Healthy Cities (AFHC) was established in 2003. Since 2002, China has launched the Health Partnership in Community programme. The programme aimed at grouping all professionals around the country together to serve the community, promote science, health, healthy lifestyle and comprehensive prevention for NCD. Using community health services centres as a focal point for networking, the health education professionals provide health promotion services to the community through large scale cross counties health forums. At the same time, in order to enhance the community awareness of the importance of health, innovative and creative ideas are used to introduce concepts so community populations have the opportunity to share the health education resources.
Hong Kong SAR: Healthy Cities, initiated in 1998, from a collaboration of NGOs, the District Council, other stakeholders including academic institutions, has initiated projects in different settings to promote better health and meet the needs of local people. There is strong support from the lay population and there has been a rapid expansion of the Alliance for Healthy.
As a continuing effort in the fight against SARS; the Operation UNITE proposed to draft the Hygiene Charter which aimed at encouraging individuals, as well as business and industry sectors, to pledge their commitment to improve hygiene practices for the good of all. The Charter puts forward suggestions and guidelines on hygiene practices for individuals, management, businesses and organizations from over 10 different sectors. The key goal is to unite the community and create a new culture of hygiene in Hong Kong. CUHK was invited to develop the Charter (Lee & Chan, 2005). The Charter has laid down the guidelines on hygiene practice, and a series of workshops for the different sectors, school teaching kits that include videos and community education programs are used to empower the population to adopt good hygienic practice.
Macao SAR: The implementation of HPS aims to stimulate the schools to mobilise community resources available to promote school health. It aims to move away from passive role of schools in participation in health promotion to active role in setting their own priorities and choosing those programmes meeting their own needs.
Research and information
The overall strategy in health promotion is to achieve mass shifts in risk factors prevalence and change in policy and organizational practice, rather than just simply focus on improving personal health literacy and behaviour modification among defined individuals. Evidence of success would be best built on data deriving from several different sources; making use of qualitative and quantitative information. CUHK has developed a set of indicators and frameworks to evaluate the effectiveness of HPS. These encompass a wide spectrum of outcome measurements based on both health and educational frameworks covering appropriate short, medium, and long term indicators with broad perspective (Lee et al., 2004a; Lee et al., 2005a). It would help to identify methods by which schools can develop as health promoting institutions, and the factors that influence this process and assess what can be achieved by schools with the use of additional resources. Youth Risk Behavioural Surveillance (YRBS) has been carried out in mainland China, Hong Kong SAR and Macao SAR periodically based on the tool used by CDC, USA (Kolbe et al., 1993). In Hong Kong, the YRBS in 1999, 2001and 2003 revealed that substantial high proportion of our young people did not have a healthy eating habit, or exercise regularly and are also emotionally disturbed (Lee et al., 2005b). The 2001 survey found correlation of youth health compromising behaviors with emotional disturbance and life satisfaction. Macao YRBS in 2003 also revealed similar pattern of youth risk behaviours as in Hong Kong. Currently a study is underway to compare the results of YRBS in 2003 amongst Hong Kong, Macao, Taipei, selected cities in mainland China and the USA. The findings would add new knowledge of changing pattern of youth risk behaviours with changing socioeconomic circumstances.
Community diagnosis has been conducted on several districts in Hong Kong to create their city health profiles before they launched the Healthy Cities movement (Lee et al., 2003b; Lee et al., 2004b). One evaluation several years after implementation of Healthy Cities shows positive results (Lam & Mok, 2006).
Evaluation of the HPS and the Healthy School Award illustrated early intervention for lifestyle changes to be effective (Lee et al., 2006). There was significant improvement in students’satisfaction with life, student health, in school culture and organisation for those schools participated in the award scheme (Lee et al., 2005c).
Health promotion programme exemplars
Health promoting schools in Hong Kong SAR
Improvement in dietary and exercise habit, mental wellness has resulted from HPS (Centre for Health Education and Health Promotion, 2006). In one school a decreased consumption of high fat snacks, sugary drinks, chocolate and candies were observed and an increase in supply and three-fold increase in consumption of vegetables at lunchtime was recorded. Bullying has decreased as has reporting of suicidal thoughts, plan or action. School health policies, curriculum, linkage with parents and community has been strengthened. Parents are provided with more opportunities to participate, support and cooperate with school to ensure the balanced development of their children. Both school social and physical environments have also been improved. The school collaborated with another gold award winning secondary school and built a healthy school network to share good practice of developing and implementing the concept of health promoting schools with other schools and kindergartens in the District. The network is now supporting 20 primary schools and pre-schools to develop as a health promoting school.
Healthy workplace project in China
The Shanghai Health Education Institute, Ministry of Health and WHO launched a model healthy workplace project in four enterprises between 1993 and 1995 (WHO, 1999). The project aims to implement a comprehensive approach with objectives to create healthy work environments, encourage healthy lifestyles and reduce the incidence of occupational diseases and industrial accidents.
Three surveys were conducted during the study period. The first survey established baseline data and guide the development of an action plan, the second to measure mid-term progress and the last to evaluate project outcomes. Using data collected from the baseline survey and focus group discussions, the factories developed multifaceted work plans focused on promoting healthy lifestyles, controlling common diseases, reducing occupational health risks, improving the general work environment and strengthening basic and occupational healthcare services. Among the outcomes were reduced smoking rates and increase in physical exercise among males, decreased noise and dust levels, development of health-promoting policies, reduced salt content in canteen food, improved health services, cleaner environment, decreased prevalence of target diseases and integration of health promotion and protection into ongoing management practices.
Healthy City programmes in mainland China
SuZhou city, winner of AFHC, has a very good infrastructure, adequate resources, has launched initiatives to involve community members and has established programmes to assist disadvantaged groups. Seminars have been held on wide range of topics to empower the citizens to lead to healthy life and policies and community actions have been developed to sustain the effect. A comprehensive set of indicators has been developed to measure the health of the population.
Healthy City Programme in Hong Kong SAR
A non-government organization, Haven of Hope Christian Service (HOHCS), initiated in 1997 the development of Tseng Kwan 0 New Town into the first Healthy City in Hong Kong. The stakeholders range from the district council, government departments, corporations, non- government organizations, schools, housing estates, commercial enterprises, community bodies to local people. Intervention included:
1. Promotion of physical activity for all, which encourages local people to walk more in daily life; multi-faceted approach encompassing interventions in the behavioral, educational and environmental aspects and through peer support by forming different physical activity groups. Collaboration with general practitioners has been effective in encouraging their patients to start physical activity for health reasons during consultations
2. Healthy Schools where interdisciplinary team of social workers, dietician and nurses collaborate with schools to provide tailored programs and activities to promote health of their students, teachers and parents
3. Sai Kung Elderly Service Coordinating Committee, as a district- wide platform organised various programs to promote physical activity, emotional health, flu prevention, fall prevention, home safety and drug safety
4. Healthy and Safe Estates where the Hello, My Neighbours! And Health Everywhere, Blessings Every Year campaigns were launched to promote neighbourhood relationship
5. TKO is My Home Community Health and Inclusion Project
Evaluation results show great success in terms of raising knowledge, understanding and commitment to health improvement.
Conclusions
The rapid economic development in mainland China and the fast pace of urbanization and industrialization has lead to a widening in health inequities and the country is also facing double challenges of NCD and emerging new infectious diseases such as HIV/AIDS, Avian Flu and SARS. Healthcare reforms have reoriented the health services towards primary healthcare with greater emphasis on health promotion and disease prevention. Policy and infrastructure need to be further reformed to involve multisectoral cooperation including NGOs and private health enterprise. Hong Kong and Macao face the impact of globalization and urbanization and need to safeguard the health of populations by monitoring and surveillance of health problems, intervening at early stage. Both SARs should build on their success in Healthy Settings to involve more stakeholders for continuous improvement and further refine the measuring tools so the success of healthy settings approaches can be evaluated.
Acknowledgements
The authors would like to express sincere thanks to Dr. Stella T. M. Chan of Macao SAR CDC for information on health promoting schools and healthy cities in Macao.
La Chine est le pays le plus peuple du monde. Par le passe, le systeme de sante publique en Chine continentale a ete fortement influence par l’ex-Union sovietique. Hong Kong et Macao, les Regions administratives speciales (RAS), quant a elles sous autorite coloniale, avaient adopte une approche de ‘laisser-faire’pour leurs politiques de sante. Au cours des deux dernieres decennies, cependant, la Chine continentale et les deux RAS ont adopte les principes de la Charte d’Ottawa, et ont reoriente leurs systemes de soins de sante vers une plus grande participation communautaire. Des environnements favorables a la sante ont ete crees dans divers lieux de vie, de meme que l’on a developpe les capacites de la promotion de la sante. Des efforts pour aller vers une approche consultative qui tienne compte des lieux de Vie favorables a la Sante, ont eu des effets positifs. Des ressources appropriees seront necessaires a la construction des infrastructures permettant un developpement durable des initiatives de promotion de la sante. Le present rapport est davantage selectif que global et met en evidence des activites promotrices de sante specifiques dans differentes parties de la Chine, refletant ainsi la maniere dont l’approche de la promotion de la sante y a evolue depuis Ottawa. Une analyse du potentiel de ces initiatives sera realisee afin de maintenir l’esprit de la Charte d’Ottawa tout en ouvrant la voie a celle de Bangkok. (Promotion & Education, 2007, XIV (4): pp 219-223).
China posee la poblacion mas numerosa del mundo. En el pasado, el sistema publico de salud de Ia China continental recibio mucha influencia de la antigua Union Sovietica. Hong Kong, Macao y las Regiones Administrativas Especiales (SAR, en sus siglas en ingles) vivieron bajo la administracion colonial que adopto un enfoque de mera tolerancia de las politicas sanitarias. En las ultimas decadas, la China continental y las SAR han aprobado los principios de la Carta de Ottawa y han reorientado los sistemas de atencion de salud hacia una mayor participacion de la comunidad, la creacion de un medio ambiente propicio para la salud en todos los entornos de vida y la capacitacion en el ambito de la promocion de la salud. Se han obtenido resultados positivos partiendo de iniciativas que incorporan enfoques mas participativos de la promocion de la salud, empleando para ello el marco de los Entornos Saludables. Si se pretende levantar una infraestructura capaz de desarrollar de manera sostenible las iniciativas de promocion de la salud se necesitaran recursos en cantidad suficiente. El informe es selectivo, mas que integral, y subraya actividades concretas de promocion de la salud realizadas en diferentes partes de la China, que reflejan la evolucion del enfoque de la promocion de la salud desde la Carta de Ottawa. Se realizara un analisis del potencial de dichas iniciativas para llevar adelante el espiritu de Ottawa como una manera de abrir camino a la Carta de Bangkok. (Promotion & Education, 2007, XIV (4): pp 219-223). References
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Albert Lee1, Hua Fu2 and Ji Chenyi3
1. Professor and Director of Centre for Health Education and Health Promotion, the Chinese University of Hong Kong; Regional Leader (NWP) of IUHPE Global Programme for Health Promotion Effectiveness. Correspondence to: Centre for Health Education and Health Promotion, The Chinese University of Hong Kong, 4th Floor, Lek Yuen Health Centre, Shatin, N.T., Hong Kong ([email protected])
2. Professor, Deputy Dean, School of Public Health, Fudan University, Shanghai, People’s Republic of China.
3. Professor, Director, Institute of Child and Adolescent Health, School of Public Health, Peking University Health Science Center, Beijing, People’s Republic of China.
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