In 1986 the Ottawa Charter for health promotion was launched by the World Health Organization and was received with enthusiasm by organisations and practitioners throughout the world.
Thirty-three years after the Ottawa Charter, health systems and governments have not embraced health promotion to its fullest potential. Barriers exist as professionals and policy makers continue to respond to community pressure to meet crisis demands but rarely promote health holistically. In addition, many professions are still influenced by independent models of health and care promoted by their specific discipline but rarely see the full picture. These policy and practice challenges have made the wide scale implementation needed for societal uptake daunting. New strategies to promote the implementation of the Ottawa Charter and health as a whole are needed, and frameworks such as the Circle of Health hold the potential to guide this process.1
The Circle of Health©, an innovative health promotion framework developed in 1996 on Prince Edward Island (PEI), Canada’s smallest province, continues to inspire hope as a tool to address urgent public needs while using a progressive, holistic approach to public health the Circle of Health integrates health promotion strategies (Ottawa Charter), determinants of health, social theory and six key values. It is supported by a simple learning guide. While developed and validated to meet local needs, this framework has been embraced nationally and internationally and is available in 6 languages – English, French, Spanish, Portuguese, Serbian and German.
Often referred to as “the people’s framework” as it brings together and extends the approaches taken in existing models, it reclaims ancient wisdom and holism from the Aboriginal Medicine Wheel, integrating values as a foundation for creating and sustaining health in communities, families and organisations.
The Circle of Health gained international attention without formal endorsement by a federal or international public health agency, and before scaling up health promotion innovation was mainstream. This article will introduce the reader to a framework that has multiple benefits in promoting intersectoral and interdisciplinary collaboration for population health, presenting the story of its development, application, unique qualities, impact and unwavering commitment by its champion and circle of champions.
The Circle of Health story
In the early 1990s, policymakers on Prince Edward Island (PEI), Canada embarked on a new policy direction based on a population health approach, embracing principles of health promotion and primary healthcare as set out by the Ottawa Charter3 and Alma Ata Declaration.4 A restructured health system brought together disciplines within and outside of health including public health, hospital settings, social services, housing and justice. Although policy documents defined health as a ‘resource for everyday living’ (WHO, 1986), diverse understandings and expectations of health promotion made it difficult to prioritise and decide on resources. Adopting one conceptual framework that provided a shared understanding of health promotion became a priority.
In order to reach consensus on the need for a framework, a one-day forum was held with stakeholders of the health system, community and academic participants. Over 80 people engaged in a process based on adult education, qualitative research, and community development, and answered the question ‘What does health promotion mean to you?’. This theoretical question guided the process and generated creativity and engagement. Existing frameworks were also introduced; and it was concluded that like a blueprint for building a house, a framework was necessary for developing a health promotion strategy for PEI – one in which everyone could feel represented.
What followed was another one-day session with a smaller group of health system and community representatives facilitated by Irv Rootman and Larry Hershfield from the Centre for Health Promotion, University of Toronto. Guided by the work from the previous day, this group defined the three primary purposes of the PEI Framework: to promote shared understanding of health promotion, facilitate partnership development and guide strategic planning. The group then reviewed existing health promotion frameworks such as the Ottawa Charter3 and Health for All4 to select one which would achieve the purpose; explicitly include the values identified the first day; and achieve the group’s vision of a handheld framework which could be respected and used by policymakers, academics and the community. It was concluded that none of the existing frameworks met the criteria. This presented an unexpected challenge.
One particular influence at this point was the conceptual linking of Bhatti and Hamilton’s Population Health Promotion Model which integrated the Ottawa Charter, determinants of health and social theory visually in a cube.5 In 1995, the model was in draft form and did not reference values; so in keeping with the need to incorporate values and elements for planning (what, who, why and how) in a handheld tool, time was invested in a ‘right brain’ process to conclude a design. Small groups began drawing an image of what might work; and one group, stimulated by the visual of the compass rose on a nearby wall, discovered a means of layering the four elements to integrate them in one moveable framework. With the compass rose serving as the inspiration for the first design and draft framework, the new framework for PEI had evolved beyond initial expectations of adopting an existing framework to bringing together the elements of many frameworks into one creative visual. For those who recount that process, it was a powerful and spiritual moment.
The validation process which followed involved five focus groups and resulted in affirmation of the framework concept and design. To ensure broad community acceptance, consultations with community groups were held. People with intellectual disabilities provided a key message – ‘Don’t change the words – teach us what they mean’ – while self-help, literacy and aboriginal groups suggested and affirmed the addition of the Aboriginal Medicine Wheel and a plain language learning guide. At the time of its development, the framework did not have a name. But as the story, concept and the design were shared and validated, the name Circle of Health was born. The Circle of Health was launched in June 1996 by the PEI Women’s Network and copyright was assigned to the PEI Health and Community Services Agency.
While the Circle of Health had momentum, the path to local uptake was not without challenges. In November 1996, there was a provincial election and government change. Health reform policy documents were dismantled and discredited, including the Circle of Health. Government employees could no longer publicly embrace the framework. From this point forward, the uptake of the Circle of Health in PEI was driven by the community and its champions within and outside PEI.
With increased dissemination of the Circle of Health outside PEI, demand for the Circle grew. By 1997, the Circle of Health had been distributed to 20 countries and 10 Canadian provinces. In one Canadian province, Newfoundland and Labrador, public health leadership invested in using the Circle of Health to educate health practitioners and the public about health promotion. They devised grant applications requiring completion of a workplan colour coded by rings of the Circle of Health. This serves as one example of the innovative ways in which the Circle of Health was embraced.
A Champions Story
According to literature, change requires a champion.12 I am often introduced in this role. As Director of Community Development and Health Promotion for the PEI Health and Community Services Agency from 1994 to 1996, I had the responsibility of providing leadership on new policy direction. As a nurse educator, I understood it was good practice to begin organisational planning by adopting a conceptual framework; so it made sense to apply this experience to health promotion. I consulted with Irv Rootman, Director of the University of Toronto Health Promotion Research Centre and Tariq Bhatti, Director of Health Promotion Development, Health Canada on an approach. They supported my thinking and offered to participate. I also was part of a European Union Research Development Project working with Leslie Boydell, from Northern Ireland. As a key public health leader in that country she was dealing with similar issues – how to shift community and health system thinking to a health promotion philosophy. She also was interested in being a part of this process. With outside expertise and PEI health system and community partners on board, we engaged the broader community. This began the partnership which developed and mobilised Circle of Health.
Excited by the experience and the power of development, I was enthusiastic about implementing the Circle of Health to guide an inventory of programmes, develop an evaluation framework and conduct research; when I learned I had breast cancer. At this time, quite unexpectedly, I could relate the application of the Circle of Health to my own health issue. I found myself staring at a copy of the Circle of Health on the bulletin board above my desk and feeling energised. Only later would I come to realise that the graphic artist had aligned the colours of the rings of the Circle to the chakras and that the Circle of Health was serving as a mandala.7 As my treatment progressed, I began using the Circle of Health to plan my own care, identify and mobilise my personal and community resources. I explored music, alternative therapies, exercise and meditation.
While challenged physically, I would rely on the spiritual, mental and emotional components of health; and when I felt off balance I would focus by reminding myself to ‘go back to the centre’. When I completed treatment, I needed to give my mental and spiritual self a rest. On reflection, I had more than a professional excitement about the Circle of Health – I had a personal relationship. I learned that health promotion can be fostered at all levels of care and that the Circle of Health can be used by an individual, family or community.
Once I recovered from treatment, I left the government. In 1998 I founded The Quaich Inc., a health promotion consulting company, continuing my passion for health promotion. I realised very quickly that without an investment, the copies of the Circle of Health published in 1996 would soon be depleted and there were no funds for republishing. I wanted organisations to have access to the Circle of Health, so initiated a contract with the PEI Department of Health to distribute the framework.
The uptake of the Circle of Health outside PEI motivated me. I launched into action with ideas to get this tool out to the people who need it most for policy development and implementation. In 2003, I led the development of an Advisory Committee for the Atlantic Summer Institute on Healthy and Safe Communities (ASI). The Circle of Health was adopted by the ASI as its planning and curriculum framework and continues to guide the development of programming today.
To ensure the ongoing relevance of the Circle of Health, I sought international reviewers from the UK, USA, Australia and Canada. With positive feedback on its relevancy and requests for support by users, a website www.circleofhealth.net, online workshops, facilitator manual and supplemental knowledge translation tools were developed to share knowledge and skills for applying the Circle of Health. My belief was that the Circle of Health should be in the hands of all that could use it.
Since then, and through international work funded by the Canadian Public Health Association and Canadian International Development Agency, I was invited to share the Circle of Health in workshops in Brazil as part of the AIPS project (2008) and in Serbia as part of the revitalisation of public health post-civil war (2009). My experience in these two very different cultures reinforced the Circle’s applicability across cultures and languages. Facilitation using the Circle of Health fostered collaboration and learning across disciplines; and in each country there was excitement about its potential for guiding transformative system and societal change.
To celebrate the 15th anniversary of the Circle of Health in 2011, I commissioned a YouTube documentary of its evolution; and for its 20th anniversary in 2016, I introduced the Circle of Health as a planning framework for the 6th Global Forum on Health Promotion.8 In advance of the Forum, The Quaich invited five international panellists known to share their work with the Circle of Health.9 The message across presentations was that the tool has the power to transform thinking to a more holistic, socioecological approach to health. When participants at the 6th Global Forum on Health Promotion were asked how the Circle of Health (COH) could add value in implementing the Sustainable Development Goals (SDGs), some comments were:
- The COH is a user-friendly accessible tool used by stakeholders across many sectors that do not have a health promotion background; stakeholders apply the Circle of Health and it can help frame conversations in a broader way.
- The COH is a neutral tool that doesn’t prioritise one opinion over another but can help bridge understanding to achieve common goals.
Having had the online workshops evaluated by Dais Rocha, University of Brasilia and recently adapted as a credit course for Furtwangen University, Germany; and with ongoing interest internationally and the potential afforded by the SDGs, I am re-energised and inspired to work with others and further champion this amazing tool.
The Circle of Health – applications and impact
An initial evaluation of the Circle of Health in 1997 reported that it was being used by researchers, educators and practitioners in a variety of settings and in many areas of the world.10 What was unclear was how they were using it. An online conference, ‘Sharing the Circle – Telling the Story’, adapted the story dialogue method to online facilitation and featured stories by international users of the Circle of Health.11,12 With discussions in written form, transcripts of proceedings could be analysed for themes. We learned that the Circle of Health appealed to a wide range of learning styles by integrating many concepts in one visual. We also learned that the greatest barrier was the divide between practical and conceptual thinkers. The need for facilitation which could address that barrier was identified; and the 2004 call for reviewers reinforced the need. There we heard comments that the Circle of Health serves as a ‘trigger tool’ and a ‘mind expander’ and learned that some users were spontaneously developing innovative ways of using the Circle of Health to meet local need. Included are a few case studies:
Promoting health promotion in Serbia
The Public Health Association of Serbia (PHAS) is a membership-based, nongovernmental not-for-profit association which advises on and facilitates the formulation of sound policies and programmes to promote good health practices. It was established in 2003 by a group of like-minded public health professionals and is supported by the Canadian Public Health Association (CPHA), with funding under CIDA’s ’Strengthening Essential Public Health Functions in the Balkans’ initiative (2001 – 2005). On the request of PHAS, financial and logistic support were provided by CPHA for translation of the Circle of Health to the Serbian language, as well as the organisation of a summer school titled ‘Determinants of Health – understanding and implementation of the Circle of Health’ in June 2009, established to educate PHAS members on use of this tool. In 2010, another summer school used the Circle of Health for project development in area of drug abuse, smoking prevention and prevention of alcoholism between youth in local community.
Results: Based on this positive experience, teaching materials were prepared and mobilised for Serbia and neighbouring regions (North Macedonia and Republika Srpska, a territory of Bosnia and Herzegovina). Representatives of the Medical Faculty University of Belgrade implemented the Circle of Health in teaching undergraduate medical students about health promotion research and practices. The Circle of Health is now part of the textbook of Social Medicine published in 2012, under the chapter of Health Promotion, pp 149 -169 (the editor of the textbook is Prof Dr Snezana Simic). Plans for further dissemination are considered. (Prof Dr Snezana Simic, Presentation – Workshop in advance of 6th Global Forum on Health Promotion, 2016).
Research – assessing health interventions for refugees in Germany
The immigration of many people (including refugees) poses various new challenges to societies and the health system for example the (often) low language skills and the compromised health due to pre-, peri- and post-migration issues. To meet the need of the 1.5 M refugees and 19.3 M people with migration background in Germany, multiple approaches were developed but rarely known and are never brought together and looked at as a whole. The Circle of Health was used to (a) explore the existing health promotion interventions and gaps in Germany and (b) assess the adequacy of the Circle of Health as a tool.13
Method: A systematic research of online-documented health literacy interventions was conducted, using the Circle of Health to (1) identify relevant actors and approaches (2) support data management (3) analyse and describe approaches (4) define gaps in the health approaches and (5) inspire the development of other promising interventions.
Results: More than 400 interventions were identified and then structured along the dimensions of the framework. The most common approaches in Germany addressed language barriers within the health care system by using translators and providing multilingual, written health information but also promoting health literacy in camps and German as a second language courses. The Circle of Health helped raise awareness of unaddressed areas (living situation, uncertain future perspectives, acculturation) and underlying values. It is now being used to guide program development for refugees and conduct additional research. (Stefanie Harsch, University of Education Freiburg, Germany. Presentation – EUPHA Conference, Slovenia, 2018).13
Building cross-sector partnerships for health in all policies – Belleville, Ontario, Canada
With rising rates of obesity and chronic disease, Hastings Prince Edward Public Health wanted to change the way people think about healthy eating and active living. A situational assessment was completed which identified evidence-informed policy options for improving access to active transportation, active recreation and healthy local food, and measured the attitudes of the public and decision makers to gauge their level of readiness for policy change. A tailored, multifaceted strategy of communication, municipal engagement, resident engagement, partnership development and strategic planning was initiated.
Results: Workshops on bicycle friendly communities were held, a Let’s Grow! Community Gardens Network developed and broad community support for non-motorised trails enhanced. Further initiatives and an evaluation were undertaken; and it was concluded that the Circle of Health strengthened the planning process through integration of multiple strategies, values, partners and populations. (Tanya Hill, Presentation – Workshop in advance of 6th Global Forum on Health Promotion, 2016).
Health promotion education – undergraduate students, Acadia University, Nova Scotia, Canada
Professor Barbara Anderson of Acadia University, Canada wanted a framework to underpin her course in Community Health and provide a foundation for a theory-based approach to community nutrition. In her 30-year experience as a public health practitioner, she had observed that many staff were individually focused in their approach to health promotion, and she wanted to ensure that students who graduated from her program understood the Social Determinants of Health and appreciated the complexity of health. She adopted the Circle of Health as the sole text for her students and set up assignments where they explored the content and concepts in a community project, reflective papers, Café conversations and evaluations.
Results: Through this experience, she concluded that using the Circle of Health met her objectives, challenging student assumptions and increasing understanding of the complexity of health. Professor Anderson continues to use the Circle of Health as the sole text for teaching health promotion. (Professor Barbara Anderson, Presentation – Workshop in advance of 6th Global Forum on Health Promotion, 2016).
Knowledge exchange – Atlantic Summer Institute on Healthy and Safe Communities, Canada
The Atlantic Summer Institute on Healthy and Safe Communities (ASI) strives to develop leadership capacity for sustainable, inclusive communities in Atlantic Canada. ASI adopted the Circle of Health as its planning and curriculum framework in 2004 and consciously uses it in programme planning each year. The purple ring commits ASI to policies and programmes in keeping with its values. The yellow ring brings focus to development of skills to strengthen community action, create healthy public policy and reorient human services. The yellow ring also reinforces the fact that personal skills are supported by creating supportive learning environments which meet physical, mental, spiritual and emotional needs (orange ring). The green ring guides planners to consider needs of participants, individuals and families and design a programme that focuses on communities, systems and society. The blue ring brings focus on the determinants of health. The recent programme is visible on the website www.asi-iea.ca.
Results: ASI now has a reputation as being unique in providing an opportunity for policymakers, community organisations, academics and practitioners from different cultures and languages to come together and explore new evidence and best practice in addressing population health issues each year. Follow-up evaluations document a high level of inter-sectoral and interdisciplinary collaboration. (Kirsten McKnight, The Quaich Inc., ASI 2018 Evaluation Report)
The Circle of Health continues
While the health system structure which provided leadership for the development of the Circle of Health no longer exists, the Circle of Health continues to resonate with users and attract interest. Developers of the Circle of Health attribute its creation and unanticipated uptake to the integration of theory and practice, discussion of vision and values, shared leadership, respectful attitudes, context and creativity. Experience over time attributes its longevity to added factors of having a champion and a widening circle of champions.
Creating a global shift in health promotion philosophy takes time and a transformative change in thinking amongst a broad range of policymakers, educators and practitioners. To date, the stories of the Circle of Health show how it guides change in education and practice. What is still required is evidence of its influence on policy change and documentation of improvement in population health.
Through online workshops, onsite facilitation, consultation with organisations and systems and spontaneous innovation, my hope is that the Circle of Health will be used to address a broader range of local and global health issues, promoting system change, minimising health inequalities and increasing the integration of vulnerable populations.
The Circle of Health’s success has caused me to be brave, passionate and dream big for sustainable and lasting changes to public health across the world. I am optimistic!
1 PEI Health and Community Services Agency (1996) Circle of Health: Prince Edward Island’s health promotion framework. Charlottetown (PE, Canada)
2 The Quaich Inc. (2011). Circle of health facilitator’s handbook: Knowledge, application, skills. Charlottetown, PE: The Quaich Inc.
3 World Health Organization, Ottawa Charter for Health Promotion. Copenhagen: World Health Organization Regional Office for Europe, 1986.
4 World Health Organization, The Alma Ata Declaration, 1978
5 Hamilton N, Bhatti T. Population health promotion: an integrated model of population health and health promotion. Ottawa: Health Promotion and Development Division, Health Canada; (1996). Online at: http://www.phac-aspc.gc.ca/ph-sp/phdd/php/php.htm.
12 Thompson, G., Estabrooks, C., & Degner, L. (2004) Clarifying the concepts of knowledge transfer: a literature review. Integrative Literature Reviews and Meta-analysis. The Authors.
7 Mandala (any of various geometric designs (usually circular) symbolising the universe; used chiefly in Hinduism and Buddhism as an aid to meditation) from http://wordnetweb.princeton.edu/perl/webwn?s=mandala
8 Health Promotion ~ At the Very Heart of Sustainability, 6th Global Forum on Health Promotion (2016), Alliance for Health Promotion, Geneva, Switzerland.
9 Learning from International Experience: The Circle of Health in education, policy and research (2016), a workshop in advance of the 6th Global Forum on Health Promotion. The Quaich Inc., Charlottetown, PEI, Canada.
10 Circle of Health – The Story of its Development, Third Printing, (2009). The Quaich Inc., Evaluation, p. 27
11 Smith, N., editor. Sharing the Circle- Telling the story: an online conference, Volume 1. Charlottetown, PEI, Canada: The Atlantic Centre for the Study of Human Health; (2000)
12 Labonte, R. & Feather, J. (1996) Handbook on Using Stories in Health Promotion Practice. Ottawa: Health Canada
13 Harsch S., Beattie-Huggan, P., Steinhausen, K., Saboga-Nunes, L. & Bittlingmayer, U.H. Applying the Circle of Health to analyse health interventions for people with refugee experiences in Germany. The European Journal of Public Health 28 (suppl_4)
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