Explain health promotion using the Ottawa Charter, distinguish primary, secondary and tertiary prevention, and analyse the role of advocacy in shaping Australian health outcomes

What this sub-topic is asking

NESA wants you to explain how health is promoted at a population level using the Ottawa Charter framework, distinguish the three tiers of prevention (primary, secondary, tertiary), and analyse the role of advocacy in changing the policy and social conditions that produce health. Strong responses use named Australian programs as worked examples rather than abstract claims.

The answer

Health promotion is the process of enabling people and communities to increase control over, and improve, their health. It targets the upstream conditions (policy, environment, community capacity, services) that shape health, not just individual behaviour.

The Ottawa Charter (WHO, 1986)

The Ottawa Charter for Health Promotion was adopted at the first International Conference on Health Promotion in Ottawa in 1986. It sets out five action areas that remain the dominant global framework for health promotion.

1. Build healthy public policy

Use legislation, taxation, regulation and procurement to make the healthier choice easier or the unhealthier choice harder. Examples: tobacco plain packaging, alcohol excise, mandatory food labelling, seatbelt and helmet laws, sugary-drink levies (where adopted).

2. Create supportive environments

Shape the physical, social, economic and natural environments that surround people. Examples: smoke-free public spaces, urban active-transport infrastructure, healthy school canteen policies, workplace mental health initiatives.

3. Strengthen community action

Support communities to set priorities, plan and act on their own health concerns. Examples: ACCHSs (community-controlled governance is the model in action), local Healthy Together coalitions, community-led suicide prevention.

4. Develop personal skills

Build health literacy, behavioural skills and decision-making capacity through education, information and skills training. Examples: school PDHPE and HMS programs, parenting programs, quitlines and self-help apps, peer education.

5. Reorient health services

Shift the health system's focus from acute treatment toward prevention, primary care, community engagement and the social determinants of health. Examples: GP-led chronic disease management plans, the expansion of community mental health, integrated care models, NACCHO-led primary care.

The three tiers of prevention

Primary prevention

Stops disease before it occurs by reducing exposure to risk or boosting protective factors. Examples: childhood immunisation, tobacco taxation, road safety regulation, sun protection campaigns, healthy school food policies.

Secondary prevention

Detects disease early when it is more treatable. Examples: BreastScreen Australia, the National Bowel Cancer Screening Program, the National Cervical Screening Program, blood-pressure and cholesterol checks at the GP.

Tertiary prevention

Reduces the harm and complications of established disease through treatment, rehabilitation and chronic disease management. Examples: cardiac rehabilitation, diabetes self-management education, mental health relapse prevention, post-stroke physiotherapy.

A balanced national approach uses all three tiers; over-reliance on tertiary prevention is the most common Australian system criticism (treating disease after it occurs is more expensive and less equitable than preventing it).

The health-promoting school framework

The health-promoting schools approach, developed by the WHO, integrates the Ottawa Charter into schools: school policy (canteen, anti-bullying, sun protection), physical and social environment, curriculum (PDHPE / HMS), school health services, and community partnerships. The framework is a working example of multi-action-area health promotion in a single setting.

Advocacy: policy change versus awareness

Advocacy is action to change policy, system or environmental conditions in favour of health. It overlaps with health promotion but is more specifically aimed at decision-makers (governments, regulators, employers, corporations).

Policy-change advocacy. Targets laws and regulations: e.g. Cancer Council and Heart Foundation work on tobacco plain packaging, advertising restrictions and excise; public health groups on alcohol pricing and gambling reform.

Awareness-raising advocacy. Targets public opinion and individual behaviour: e.g. R U OK? Day for mental health conversations, social media campaigns on bystander intervention or vaccination.

The two are complementary; awareness without policy change rarely shifts population outcomes (the Australian tobacco story is a clear case where policy change, sustained over decades, drove the population reduction).

Examples in context

Example 1. Cancer Council Australia tobacco control advocacy. Cancer Council Australia has been a sustained advocate for tobacco regulation: contributing to the evidence base for plain packaging, supporting excise increases, campaigning for smoke-free environments and funding the Quitline. The 2012 plain packaging legislation (the world's first) was the product of decades of coordinated policy-change advocacy by Cancer Council, the Heart Foundation, public health academics and the Commonwealth Department of Health. The case shows how non-government health advocacy moves population health outcomes through legislation rather than only through awareness.

Example 2. Heart Foundation salt-reduction work. The Heart Foundation has been a long-running advocate for cardiovascular health, including campaigns on diet quality, salt reduction in processed food, women's heart health awareness, and physical activity guidelines. Its salt-reduction work has engaged the food industry and government on reformulation targets; it has also supported the Tick / Health Star Rating discussion on front-of-pack labelling. Whatever the limits of voluntary reformulation, the case illustrates how an NGO can advocate across all five Ottawa Charter action areas (policy, environment, community, personal skills, services) on a single risk factor.

Try this

Q1. List the five action areas of the Ottawa Charter for Health Promotion. [5 marks]

• Cue. Build healthy public policy; create supportive environments; strengthen community action; develop personal skills; reorient health services.

Q2. Distinguish between primary, secondary and tertiary prevention, with one Australian example of each. [6 marks]

• Cue. Primary = childhood immunisation or tobacco excise (prevents disease occurring). Secondary = BreastScreen Australia or the National Bowel Cancer Screening Program (early detection). Tertiary = cardiac rehabilitation or diabetes self-management (reduce complications and harm).

Q3. Using Australian tobacco control as a case, analyse how the Ottawa Charter action areas combined to reduce smoking rates over time. [8 marks]

• Cue. Map each action area to a named intervention: healthy public policy (excise, plain packaging 2012, advertising bans), supportive environments (smoke-free legislation), community action (Tackling Indigenous Smoking), personal skills (Quitline, school PDHPE), reorient health services (GP brief intervention, PBS-subsidised cessation aids). Note the role of Cancer Council and Heart Foundation policy advocacy. Reach a judgement that multi-action-area work over time produced the population reduction, no single intervention would have.