How international is health promotion?

As an international journal, Health Promotion International ( HPI ) prides itself to be an exponent of the international health promotion movement. After all, health promotion is not only a multidisciplinary field of research and practice that unites professionals from within and beyond the health sciences to develop and apply methods to improve the health of individuals and communities; it is also an international movement that seeks to move health out of the professional action frame and engage and empower people to increase control over their health. Although the problems health promotion addresses are generic and global, their manifestations and determinants are largely defined by local conditions and cultural influences. Addressing these determinants requires context relevant and culturally appropriate interventions: Depending on the health problems faced and the resources available in a country, priorities differ, and so do the actions that can be undertaken to tackle these problems.

By sponsoring the exploration of practical experiences to bring the Ottawa Charter strategies into action, the World Health Organization (WHO) has played a leading role in fostering the global health promotion movement, which has gained response from countries throughout the world. It suffices to attend an international health promotion conference to witness the rich variety of actions, programs, methods, tools and techniques that are used by health workers from across the world, and to appreciate how these actions take context and culture into account.

The need to consider international and cultural diversity is also recognized in the global thinking about health promotion. The Bangkok Charter for Health Promotion ( WHO, 2006 ), for instance, affirms that health promotion is a cultural as well as a social, environmental, economic and political process, and makes a plea to balance globalization with local action so as to preserve cultural diversity. Similarly, the WHO’s Global Programme on Health Promotion Effectiveness ( WHO, 2016 ) takes regional and cultural diversity into consideration when focusing on the principles, models and methods of best health promotion practice. And in terms of training and capacity building, the ComPH Core Competencies Framework endorsed and implemented by the International Union for Health Promotion and Education ( Barry et al., 2012 ) explicitly mentions a respect for, and sensitivity to, all aspects of diversity as one of the core values and principles underpinning health promotion, and refers to the use of culturally relevant and appropriate approaches, methods or techniques for diverse cultural, socioeconomic and educational groups in several core competency domains.

So where does health promotion research stand in this? Does it reflect the international dimension and the cultural diversity that is present in the practice and the thinking of health promotion? A look at the contents of the current issue of HPI makes us feel optimistic: the 24 contributions of this issue reflect the work of scholars from 17 different countries, representing all 6 continents. Although the ‘diversity’ is relative (17 of the papers originate from western countries in Europe, Australia or North America, compared to only 4 from Asia, 2 from Latin America and 1 from Africa), it does reflect a clear trend towards internationalization. Thus far, the 2016 volume of the journal has published original papers, perspectives and debate contributions from no less than 40 different countries. In comparison, the 37 papers published in the 2006 volume represented only 16 countries, and with the exception of five all of them were concerned with research carried out in Europe, Australia, New Zealand, the USA or Canada.

This marked rise in the number of articles from a broad range of countries, and particularly written by non-western researchers, is not fortuitous. The editorial team of HPI made the deliberate choice a few years ago to encourage submissions from low- and middle-income countries and enhance the international character of the journal. This was part of a broader strategy to strengthen the geographical, ethnic, gender and other diversity of the journal—a strategy that is also reflected in the composition of the journal’s Editorial Board. We developed this stance also in response to the challenge formulated by Mohammadi et al. (2011) who observed that diverse authorship may increase but Editorial Board composition may not. This policy now seems to bear fruit, in the way that a richer variety of projects, policies, activities and processes from the global health promotion community finds its way to the journal. Although a similar trend is noted in some other journals, HPI is leading the way by publishing more international research than any other journal in the field. What is more, an increasing number of papers present findings of studies that involve several countries, are written by an internationally composed group of authors, and look for similarities and differences in the ways health promoting interventions are implemented in different countries. Add to this the number of papers describing adaptations and validations of existing tools, guidelines and methods to better suit local needs and context, and it is safe to conclude that the international dimension of health promotion is increasingly recognized by researchers.

But this may not be good enough. If health promotion research is to be truly international, it should not only reflect the movement towards internationalization, but actively support it. That implies, first of all, that the methods to address international and intercultural differences receive more attention in published research; and secondly, that international and cultural diversity is not only present in the authorship of publications but also in their content.

The first point links to the well-known fact that health promotion interventions are more effective when they are adapted to the context. When applied internationally, health promoting initiatives should therefore be adapted to the local situation and culture. Culture can be defined as the learned and transmitted values, beliefs and practices of a particular group of people that guide thinking, decisions and actions in patterned ways ( Leininger, 1985 ). The seminal work of Kreuter et al. 2003 on cultural tailoring shows how culturally sensitive interventions can be developed by adapting existing materials and programmes to the needs of the population. One way of achieving this is to match materials and messages to observable ‘superficial’ (although important) characteristics of a population, such as well-known people, places, language, music, food and locations. Another way is to recognize and reinforce the values, beliefs and behaviours of the community, which requires an understanding of ‘deep culture’. Whereas adapting to the surface culture increases the acceptance of programmes, addressing deep cultural factors is believed to enhance their effectiveness and sustainability ( Resnicow et al, 1998 ). So, ideally, health promoters who work in an international context should identify and describe cultures and/or subcultures within a given population, understand how each relates to health determinants, and apply this knowledge in planning and development activities. In practice, however, culture is more often assumed than assessed, and the way in which adaptations are made often remains undocumented. Most international adaptations of programs or materials only change the surface cultural aspects, for instance by tailoring the language of reading materials, whereas aspects of deep culture such as cultural history, values, norms and cultural perceptions of health and disease are very seldom addressed. As such, the international dimension of health promotion would greatly benefit if researchers would apply cultural tailoring strategies more systematically and describe these strategies more explicitly in publications about their research.

Furthermore, health promotion scholars from across the world should be encouraged to not merely reproduce and adapt western approaches to health promotion but to enrich and expand them. There is a wealth of important and critical developments in health promotion taking place in non-western parts of the world which remains unknown to the international research literature. In part, this is due to a lack of human and financial resources that are required for active dissemination but there are also cultural barriers that hinder the translation and communication of potential innovations. A critical point in this regards is the difficulty of working across countries and cultures on the issues of evidence and effectiveness ( McQueen & Jones, 2007 ). For instance, in many cultures promoting health involves a spiritual component, through interventions involving healing, praying or meditation. Mainstream health promotion does not consider spirituality as an intervention model, due to a lack of empirical evidence ( Gorin & Arnold, 2008 ). By developing operational measures of the concept and performing rigorous evaluations of interventions that use spirituality scholars from different parts of the world could add to the credibility of this non-western approach and thus enrich health promotion. In a similar vein, research originating from countries with more collective and community-based societal models could provide a welcome counterbalance to the strong individual bias that characterizes health promotion in western societies, and serve as an ideal testing ground for participatory approaches such as empowerment implementation ( Van Daele et al. 2014 ) or empowerment evaluation ( Fetterman, 1996 ). On the conceptual side, notions that are unique to specific cultures can enrich the vocabulary and actions of health promotion. For example, the Portuguese-Galician notion of saudade ( Silva, 2012 ), which refers to a melancholic state of incompleteness reflecting both sadness for missing experiences, places or events that once brought pleasure and well-being, and happiness for having experienced these feelings, is key to understanding health in lusophone cultures. It could be a welcome addition to understanding the meaning and experience of health in other cultures as well.

Although enriching the ideas of health promotion through input from other countries and cultures is a long term process, it does not have to start from scratch. In the past, health promotion has gratefully adopted and incorporated notions and approaches from languages and cultures that are less well represented in the mainstream scientific literature. The inclusion of the key concept of empowerment ( Freire, 1973 ) in the Ottawa Charter is a case in point. This trend should be both continued and strengthened by giving more space to international research. Several authors have highlighted the potential value of other non-western systems and approaches for health promotion. For example, De Leeuw and Hussein (1999) argue that the Islamic value system, which is often considered to be in opposition to western perspectives, in fact includes many of the notions of health promotion, such as the role and responsibility for health authorities, communities and academics to apply the principles of the Quran to current social and health challenges. Acknowledging this similarity could increase the ‘interculturalization’ of health promotion, which would facilitate the implementation of contemporary health promotion in Islamic nations but also the reaching out to Islamic communities in Western countries. In a similar way, Williams et al. (2003) showed the potential of storytelling as an empowerment practice, drawing on the experiences of migrant Tongan and Samoan women in Aotearoa/New Zealand, indicating that there is much empowering scope in the use of storytelling with communities at the economic and social margins.

Whereas health promotion originally seemed to have had a ‘western’ thrust, its current global dimension is what gives it its flavour and impact. It is therefore a matter of course that the international health promotion movement would be both reflected in and supported by the research community. For that reason, HPI invites contributions from across the world that introduce and evaluate concepts and approaches receiving little attention in western research, and that describe the development, planning, implementation and evaluation of interventions that truly reflect international diversity. The journal also particularly welcomes contributions involving the collaboration between researchers from different countries, and encourages authors to document the ways in which the international and intercultural diversity is accounted for when setting up actions in health promotion. By publishing papers that meet the above descriptions, HPI will be able to fully live up to its mission to remain the thought journal of the international health promotion movement.

FUNDING

The author declares no funding was received for this article.

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