Health promotion is historically undertaken by a wide range of people and organizations - governments, non-governmental organizations and primary care service providers - but in a poorly integrated fashion (Rowan et al., 2007). As primary care is the main gateway to the health care system for most people, the focus in this section is on integrating food into primary care. Traditionally focused on individuals and families, the role and structure of primary care has been shifting slowly. The links between public health and primary care are traditionally weak, though this has improved over the years for infectious diseases. There have also been modest improvements related to chronic diseases, such as type II diabetes and heart disease, associated with using health promotion approaches within primary care to reduce mortality and morbidity and some risk factors. Health education is one among many health promotion elements that have contributed. Diet and nutrition have also been important. However, these are really just baby steps and fuller integration is required.
There are three levels at which integration can happen: at the level of financing and regulation of activities (sometimes called the macro level); at the community level, with both organizational and professional integration (meso level); and at the clinical level (the micro level). Most of what's currently happening is at the community and clinical levels, reflected in the different team practice models, in revamped clinical guidelines and in surveillance communication. Less is happening at the macro level except that teams are often funded differently than traditional fee for service and given that teams are working on both primary care and health promotion, a certain level of financial integration is underway. There are also new incentives in the physician funding schemes that prioritize some limited health promotion practices (Rowan et al., 2007).
Given that these things are underway, they are more fully discussed at the Efficiency and Substitution phases. These strategies also take account of Nutting (1986) barriers to integration, adapted to the Canadian context:
- Physician attitudes and beliefs - they are primarily responders and diagnostitians, responding to what comes to them. Many do not see it as their role to promote behavioural change or address social inequities that affect their patent's health
- The payment models
- Brevity of visits and payments
- State of knowledge of social determinants and health promotion compared to biomedical research
- Insufficient physician knowledge of the full range of health promotion issues; stronger on smoking, alcohol, inactivity, weaker on most other themes
I imagine a transition that:
- is based on health promotion principles and healthy public policy
- emphasizes community development principles and opportunities
- is evolutionary (3 stages), with each stage leading to the next
- uses primarily strategies that address multiple diseases and conditions
- uses primarily strategies that progressively integrate the food and health systems