Health promotion activities in Ontario Community Health Centres: a descriptive report

Introduction

Healthcare systems worldwide are facing aging populations, increasing complexity of care, and exacerbated costs (Dubas-Jakóbczyk et al. 2017; The Lancet Healthy Longevity 2021; Canadian Medical Association 2023; Jones and Dolsten 2024). Health promotion is a process that works to prevent disease and promote better health outcomes (Health Promotion Ontario 2023). It is defined by the Ottawa Charter for Health Promotion as ‘… the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment’ (World Health Organization 1986).

There is an ever-growing body of evidence that highlights the importance of investing in health promotion to lower disease prevalence, reduce healthcare costs and utilisation, and produce better patient and population health outcomes (McManus 2013; Masters et al. 2017; Health Promotion Ontario 2023). Yet the work of health promotion, like many other preventative interventions, often goes unnoticed and is minimally invested in. This is largely since health promotion, as an upstream approach, can be hard to assess due to multiple influencing factors as well as its impacts typically emerging in the medium to long term (Health Promotion Ontario 2023; Canadian Public Health Association 2024). The long-time horizon of health promotion outcomes makes it less desirable to invest in when compared to treatment-based efforts whose impacts can be seen relatively quickly (Health Promotion Ontario 2023; Canadian Public Health Association 2024). This is despite the fact that health promotion is overall less costly than treating health issues that have already developed (Nurse et al. 2014; Health Promotion Ontario 2023).

Health promotion initiatives can not only help relieve the strain on healthcare systems but can also help to strengthen local communities and populations’ resilience when faced with crises such as the COVID-19 pandemic (Moore 2022; Health Promotion Ontario 2023). The pandemic clearly demonstrated to us how communities with less favourable social conditions and impacted by the social determinants of health, were disproportionately affected when compared to their counterparts (Bailey and West 2020; Dorn et al. 2020; National Centre for Immunization and Respiratory Diseases (U.S), Division of Viral Diseases 2020; Toronto Public Health 2020). Ultimately, if we want to create stronger healthcare systems and healthier populations, greater investments in health promotion are needed (Masters et al. 2017).

The Alliance for Healthier Communities (Alliance) is a membership of community-governed comprehensive primary healthcare organisations located in diverse communities and geographies across Ontario, Canada. This membership includes Community Health Centres (CHCs), Nurse-Practitioner Led Clinics, Community-Governed Family Health Teams as well as Indigenous Primary Healthcare Organisations (Rayner et al. 2018). CHCs are comprehensive, interprofessional, salary-based primary healthcare organisations with a long history of serving marginalised communities and addressing social determinants of health. They deliver coordinated and integrated team-based primary care through an evidence-informed model of care called the Model of Health and Wellbeing. The model provides a roadmap for delivering care including health promotion, that is comprised of three guiding principles; Highest Quality, People- and Community-Centred Primary Health Care; Community Vitality and Belonging; and Health Equity and Social Justice (Rayner et al. 2018).

Through health promotion, CHCs work to address and mitigate the impact of upstream social, economic, and structural factors that affect the health and wellbeing of their communities. However, as CHCs are also committed and mandated to provide care that advances health equity, centres strive to create and implement health promotion programming specifically for those in Ontario who face the most significant barriers to accessing care. As such, care is delivered according to the unique contexts and geographies in which they are located and serve priority populations such as those living in poverty, those in rural and remote areas, French-speaking populations, as well as newcomers and people experiencing homelessness (Rayner et al. 2018). This paper will describe how CHCs in Ontario, Canada deliver health promotion as part of their model of care, including: how program priorities are identified; what the priorities were and whom the programs were intended for in 2021–2022; and how these programs are implemented and evaluated. Later in the text, we describe how CHCs exemplify the work of health promotion.

Methods

To showcase the breadth of health promotion programming offered by our member centres, we pulled electronic medical record (EMR) data and conducted a series of focus groups with health promotion staff and managers to provide greater context. Using the Alliance data warehouse, a list of health promotion programs that were implemented in CHCs during the 2021–2022 fiscal year as well as the associated issues addressed (these were used to group the health promotion programs into 15 categories reflecting overall topic areas) were extracted. These data were used to create 69 individual centre reports. Each centre was asked to validate their list of programs, to suggest a topic category, and provide additional information on target populations, partnerships, funding sources, and evaluation.

Six focus groups were conducted with 72 health promotion staff and managers across 42 CHCs between February and March of 2023. A semi-structured interview guide was used to explore participants’ perspectives on what health promotion looks like in their settings, how they identify program/service priority, how they currently evaluate the impact of their work, and any suggestions on how the sector should and could highlight their work. Focus groups were held over Zoom, were recorded, transcribed, coded, and reviewed for themes and examples.

Results

In 2021–2022, approximately 2452 health promotion programs were reported amongst 69 CHCs (82% of which were urban centres), with the top three priorities for programming being social support, food security and education, and physical activity (see Table 1). Of the centres (n = 57) that validated and provided target population data for their health promotion programs, the most prevalent populations reported were the general community (24%) and children and youth (15%) (see Table 2).

Focus group participants described the common approaches for designing and implementing health promotion programming within their respective settings. This included how program priorities are identified; how programs are funded and supported by community partnerships; how programs are designed with health equity at their core; the unique opportunity of providing health promotion programs within comprehensive primary healthcare organisations; and finally, how programs are evaluated. These are described in further detail below.

Funding and community partnerships

Health promotion programs implemented in CHCs are carefully planned and designed to appropriately use limited resources and funding. They are funded through a variety of sources and often rely on grants, partnerships, and volunteers. For example, most health promotion programs (73%) offered in 2021–2022 were primarily funded by the Ministry of Health (Provincial Government) through base organisational funding (see Fig. 1). Of total organisational expenses recorded in 2021–2022, only 13.3% were spent in the areas of health promotion, education, and community development.

Fig. 1.

Personal development groups by funding source, 2021–2022.

Due to limited funding, CHCs rely upon and collaborate with municipal, regional, and provincial partners to co-create innovative health promotion programs. For example, of the 54 centres that provided partnership data, just under half (40%) of all health promotion programs were reported to be done in partnership and a total of 532 partnerships were reported overall. Partnerships were either community-based (66%, n = 349), healthcare-based (15%, n = 81), government-based (13%, n = 69), or education-based (6%, n = 33).

Discussion

CHCs in Ontario, Canada, deliver health promotion as part of their model of comprehensive primary health care and help relieve pressure on the overall healthcare system by creating programs that target emerging needs within their communities. For example, programs implemented in 2021–2022 mirrored rising concerns around loneliness and lack of social supports, food security, physical activity, and chronic disease prevalence (Deaton and Deaton 2020; Holman 2020; Lin 2023; Cancer Care Ontario 2024). Health promotion within CHCs also provides a unique opportunity of linking primary care clients to health promotion programming and vice versa, in order to better and more holistically address their concerns, which can further help to relieve pressure on primary care and the broader healthcare system. As an upstream approach, health promotion can also help to integrate different sectors outside of health care (i.e. education, government, etc.) to improve population health outcomes, which CHCs excel at given the number of reported partnerships.

Health promotion works at the population level when conducted by large public health institutions, however, health promotion can and has also made significant contributions towards impacting health outcomes at the local community level (Jackson et al. 2006; Haldane et al. 2019; Health Promotion Ontario 2023). This is achieved by delivering programs to targeted populations and taking into consideration the contextual issues communities are facing (e.g. issues related to race, rurality, etc.). This is a significant strength of CHCs as they are community-governed (e.g. needs assessments, program planning, board governance, etc.) and have strong relationships with their communities (Rayner et al. 2018). As a result, they are highly attuned to the needs of their communities and deliver programming that is locally relevant and reduces barriers to care (i.e. free of cost and subsidised transportation), especially to those who are at the greatest risk of poor outcomes.

Furthermore, health promotion conducted in CHCs empowers individuals to have a greater role in their own and their community’s health and wellbeing as all programs are created and implemented to address a need self-identified by their communities. Their peer-led model further supports this empowerment by supporting individuals in co-designing and leading programs. A systematic review on community participation highlighted that ‘Interventions that have been developed with local populations have been shown to decrease hospital admissions and mortality rates, reduce clinical symptoms related to chronic diseases, and improve quality of life and behavioural risk factors such as physical activity’ (Haldane et al. 2019).

Although, our analysis did not look at the cost-savings of health promotion programming, there is strong evidence in the current literature regarding its cost-effectiveness. For example, a 2016 systematic review looking at cost-effectiveness of public health interventions including health promotion in high-income countries, found that health promotion programs specifically had a median cost to benefit ratio of 14.4. This ratio compares the costs of a programor projects to its benefits – and a cost–benefit ratio less than 1 indicates that the costs outweigh the benefits (Masters et al. 2017). Economic evaluations on health promotion programs focused on falls prevention for older adults as well as childhood and obesity interventions also show promising results in regards to healthcare cost savings (Dubas-Jakóbczyk et al. 2017; Zanganeh et al. 2019). According to another report, every CAD$1 spent on mental health promotion and early intervention for children and youth saves CAD$2–17 in societal costs (Mental Health Commission of Canada 2013). Ultimately, by investing in health promotion initiatives, we can support and sustain our healthcare systems as well as improve population health outcomes in a cost-effective manner (Masters et al. 2017; Health Promotion Ontario 2023).

Conclusion

Evidence supporting health promotion as an upstream and cost-effective approach to help relieve pressure on the healthcare system continues to grow. In this paper, we have used EMR and focus group data to describe the implementation approach employed by CHCs in Ontario, Canada who have been delivering health promotion programming for decades. Lessons learned from this paper could be adapted by other primary healthcare organisations looking to implement health promotion that is centred around health equity and is co-designed with community.