This study investigated how the Ottawa Charter and health promotion concepts and principles have been applied across European regions and professional domains in the perspective of health promotion professionals. Regarding the perceived use of action areas in the health promotion field, "Developing personal skills and knowledge" (64%) was rated most frequently and regularly used in one’s country among participants, the highest among Western (75%) and Northern Europeans (71%) and lowest for Eastern (53%) and Southern Europeans (50%). The relatively high perceived use of educational strategies may be explained by the fact that this action area is relatively broad in potential impact with its core ideas as supplementing information, health education, and the enhancement of life skills (Ottawa Charter for Health Promotion 1986), which include many possibilities for usage. As McQueen and De Salazar (2011) explain, information can be an inactive concept, education is about broadening one’s knowledge, and skills are a means that allow an individual to undertake certain actions. As a result, developing personal skills can include a wide range of initiatives. Furthermore, as pointed out by Weare et al. (1992), before the Ottawa Charter health education had already gained ground in various countries, particularly in the school setting. Therefore, existing methods, examples, and channels were likely available and easier to apply than some of the other action areas.
Though sharing health information and education has been shown to be an area with a fair amount of use in all geographic regions, the Vienna Declaration (2016) describes the current challenge is now the overload of information as well as misinformation that is now quickly accessed by citizens (EUPHA 2016). Managing this will require creative strategies from health promoters and the public health community as well as gaining the trust and respect of the public to continue sharing and disseminating credible knowledge and skills. It is somewhat a paradox that the Ottawa Charter was created initially in response to a heavy focus on individual approaches (Thompson et al. 2017) and that—as our data indicate—after 30 years the area "Development of personal skills" still seems to play the predominant role. One potential reason for this lack of a substantial shift in focus of health promotion action towards more upstream measures which was warranted by the Ottawa Charter might be the tendency within societies with mostly neo-liberal governments to withdraw from welfare in the 1990s, which has resulted in prioritizing more individualistic lifestyle approaches (Wills and Douglas 2008).
However, it might be attributed to the Ottawa Charter and its influence in the respective countries that as second-most common, "Developing healthy public policy" was declared as used by 44% of respondents with the highest percentage among Northern Europeans (53%) and the lowest among Western Europeans (36%), although the differences between regions were not significant. In agreement with our results, others state that over the past 30 years, more attention has been given to this domain in recent years and that stakeholders interested in health are increasing (Kickbusch 2010). Although there have been good examples of policies that aim at risk factors and disease reduction, there is also concern that comprehensive national policies that integrate actions to improve health and social and economic conditions across sectors are still rarely seen (IUHPE and CCHPR 2008).
As the next most common area, 41% of participants rated "Strengthening community action" as often used, with significant differences between regions showing the highest ratings for Northern Europeans (53%) and the least for Eastern Europeans (11%). The struggle in using this domain can be in part due to its complexity, which may focus on a different purpose or require engagement in various stages at different times such as participation, or becoming concerned with building on competencies and capacities, and is directed toward specific goals and actions (Laverack and Mohammadi 2011). At another stage, strengthening community action may be assisting communities to solve issues related to their lack of power and locating or using their voice to be more politically active. This has been considered to be the catalyst for empowerment (Laverack and Mohammadi 2011), a term which, though explored in this domain, is often elusive with its absence of concrete methodologies and strong evidence in diverse settings and cultural environments (Laverack and Wallerstein 2001). Furthermore, it is possible that its reliance on reorientation of health services and professional practice as well as the political climate that influences practitioners, communities, approaches, and agendas (Laverack and Mohammadi 2011) can further complicate the use and feasibility of this action area.
Next, only 36.3% of survey participants perceived "Creating supportive environments" to be often used with significant difference between regions with again the highest ratings among Northern Europeans (49%), followed by Western (38%) and Southern Europeans (28%) and 11% among Eastern Europeans. The relatively low use of this action area is in contrast to the IUHPE and CCHPR (2008) stating that settings-based initiatives should be cultivated as health-promoting workplaces and schools tackle health determinants and behaviors. It is evident that in Europe and beyond, since the Ottawa Charter a plethora of international and national programs and networks have emerged, covering settings as diverse as regions, districts, cities, islands, schools, hospitals, workplaces, prisons, universities, and marketplaces (Dooris 2006). This can be considered major progress, but the influence is not as strong as it could have been according to Dooris (2006), and concerns exist about whether a consequence of a settings approach may at times result in fragmentation as settings operate at different levels (Dooris 2006).
Only 31% of survey respondents felt the action area "Reorientation of health services" was often used and 10% perceived it to never be used at all, without any significant differences between regions. This is not surprising as merging health promotion to the mainstream requires the investment, value, and collaboration of various stakeholders at local, regional, and global levels (Ziglio, Simpson and Tsouros 2011). Wise and Nutbeam (2007) assert that this action area has had minimal systematic attention as its own action area and with respect to the four other action areas and is still an unaccomplished agenda. Ziglio et al. (2011) state that part of this requires the reframing of messages. Also, Johannson and co-authors (2010) observed that though there may be willingness among health professionals in their Swedish sample to engage in more health promotion and disease prevention in primary care and hospital settings, several barriers such as high workload have made this challenging.
This study did not find any particular difference in ratings between respondents working in curative or practice settings compared with those in public health administration or in research, but differences according to European regions emerged. With the exception of "Developing personal skills", the perceived use of action areas in one’s geographical region was in the order of Northern Europe, Western Europe, Southern Europe, and Eastern Europe, with "Community action" and "Supportive environments" being particularly low for Eastern Europeans. Though no conclusions can be drawn in this descriptive study, this pattern may give insight to the state of health promotion and public health progress and practice in these regions. Responses from a survey studying differences in public health research among Northern, Southern, and Eastern Europe indicated that health services, health promotion, prevention, and education were indeed priorities at a national level in countries identified as Northern and Western Europe in our study (Mannoci, Ricciardi and La Torre 2009), but infrastructures and technology shortages were identified barriers in Southern and Eastern Europe compared with the North (Mannoci et al. 2009).
Though the action areas are looked at individually in our study, one must keep in mind that they are designed to interconnect, which may impact their separate and overall use. However, as Ziglio et al. (2000) point out, most health promotion activity has continued to be issue-based or else has focused on only one determinant at a time. Therefore, health promoters should also be conscious of designing interventions to actively target more than one action area at a time, recognizing and demonstrating that each domain is mutually dependent on another, and achieving a major impact on the determinants of health or policy development (Ziglio et al. 2000).
A total of 72% of participants felt that health promotion sparks interest and engagement among health professionals and policy makers. This is a promising result as increased value for health promotion among stakeholders and the public is necessary to increase its demand. Such a demand is relevant in order to avoid that health promotion occurs infrequently rather than an essential service (Johannson et al. 2010). Also promising is the results that 72.5% of respondents felt that health promotion is a necessary field, and 80% agreed that overall knowledge about the topic of health promotion has progressed over the past 30 years. This is in line with the findings from Ziglio et al. (2000) who state that the implementation of a wide range of health promotion initiatives has generated much collective experience within Europe and added considerably to both knowledge and progressive change.
On the other hand, less than half (44%) of the participants felt that the field of health promotion was well established in their country, and only 50% felt that it is currently well established in Europe. Though there have been well-known health promotion innovations in the European region since the Ottawa Charter, with the Investment for Health Approach, Healthy Cities, Health-Promoting Hospitals, and Health-Promoting Schools, to name a few, in agreement with our results, there is evidence that the overall impact of these innovations has been relatively limited in the region (Ziglio et al. 2000). It has been argued that the various social, political, and economic changes unfolding in European society parallel to the growth of health promotion have limited the impact of health promotion in different settings (Ziglio et al. 2000).
This study has limitations, as it only captures subjective perspectives regarding the relevance and use of the Ottawa Charter action areas but is unable to measure implementation in the European region. Other research aiming at quantifying implemented programs and actions in the different areas for European countries would be needed for this. Though this study indicates its focus on the European region and surveyed professionals connected to EUPHA, voices and perspectives of other countries are not captured, particularly in developing regions. The limited number of respondents (n = 18) from countries outside of Europe does not cover other relevant geographical areas. Therefore, the study widely excludes valuable perspectives on how useful or relevant the Charter has been outside of Europe. Furthermore, it excludes perspectives of those who are not yet experts or professionals, such as students or lay people. In addition, since only 8% of the health promotion section members responded to the survey invitation, the responses do not necessarily represent all section members. Furthermore, due to the limited sample size of respondents from some geographical regions, especially of those from Eastern European countries, the results regarding geographical variation need to be interpreted with caution. In the spirit of democracy, future reflections on the Ottawa Charter should seek to explore perspectives of the Ottawa Charter and its relevance from professionals outside of Europe and in developing regions as well as among non-experts. The Charter is a powerful document which should not only circulate and be analyzed within the public health community.
Though the Charter sparks motivation and hope, particularly at its conferences, a Charter with misplaced action, agreement upon, and advocacy for its principles will simply remain a Charter. Though progress has been made over 30 years, the unfulfilled potential coupled with emerging health threats may help to explain why 81% of participants in this study felt that the topic of health promotion requires deeper reflection since the development of the Ottawa Charter. It is undeniable that over the past 30 years global changes and challenges have emerged that require updated strategies to address new threats such as commercial determinants of health and non-communicable diseases, to name a few. However, as Thompson and others (2017) point out, the Charter was created in response to a heavy focus on individual approaches, which is recently a returning problem along with other challenges such as access to water or health for all, for example. The Ottawa Charter continues to be a relevant concept as its vision highlights relevant issues that have yet to be resolved and presents roles for health promoters yet to be fulfilled and action areas yet to be optimally implemented.