HEALTH PROMOTION
4
O Oxford University Press 1989
Towards an expanded health field concept:
conceptual and research issues in a new era
of health promotion
JOHN M. RAEBURN
Department of Psychiatry and Behavioural Science, University ofAuckland, New Zealand
IRVING ROOTMAN
Health Promotion Directorate, Health and Welfare Canada, Ottawa, Ontario, Canada
SUMMARY
The concepts of health promotion contained in the
Ottawa Charter for Health Promotion and the new
Canadian government policy are changing the face of
health promotion. But these concepts have yet to be
formed into a cohesive framework for the efforts of
policy-makers and others. As part of the Canadian
policy development exercise, the health field concept of
the Lalonde report was re-examined, since it had been
influential in shaping earlier policy. In this article, some
of the fruits of that examination are presented, along
with a proposed expanded health field concept that
takes account of the new concepts. The aims of the
expanded health field concept are threefold: to guide
policy, to argue for resources and to provide an analyt-
ical framework suitable for programme development
and research. Emphasis is put on five areas outside the
INTRODUCTION
Future historians of health promotion will prob-
ably divide the modern era into two periodspre-
Charter and post-Charter, referring to the first
International Conference on Health Promotion in
Ottawa, Ontario, Canada, in November 1986,
and the Ottawa Charter for Health Promotion
(1986). The earlier period originated in Ottawa,
with the publication in 1974 of the Canadian
government document usually referred to as the
Lalonde (1974) report. At the heart of this
document was the health field concept, which has
frequently been cited as a useful conceptual
model by academics (Green & Anderson, 1986)
VoL 3, No.
Printed in Great Britain
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original health field concept: output aspects of the health
promotion process (not just input); positive aspects of
input and output (notjust negative); subjective aspects of
input and output (not just objective); increased em-
phasis on social and environmental input; and clarifica-
tion of the relationship between health and quality of
life. It is suggested that, on the input side, the five action
areas of the Ottawa Charter be used as a starting point,
and that on the output side, measures focus on four
areas: morbidity and mortality, positive health indica-
tors, subjective perceptions, andfunctional capacity and
coping. The expanded health field concept represents an
evolutionary step beyond the old concept, and is pre-
sented as a stimulus to discussion rather than as the final
word
and planners (US Surgeon General, 1979). The
report (Lalonde, 1974) suggested that "the tradi-
tional view of equating the level of health in
Canada with the availability of physicians and
hospitals is inadequate", adding that "there is little
doubt that future improvements in the level of
health of Canadians lie mainly in improving the
environment, moderating self-imposed risks and
adding to our knowledge of human biology". To
help expand the concept of health beyond
medical services, the Lalonde report presented
the health field concept, which was pivotal to
everything else that followed: "Such a Health
383
384 J. M. RAEBURN AND I. ROOTMAN
Field Concept... envisages that the health field
can be broken up into four broad elements:
human biology, environment, lifestyle and health
care organization.". Of these four elements, the
one for which the Lalonde report is probably best
remembered is lifestyle. In 1978, the Canadian
government moved to act on this report by setting
up the Health Promotion Directorate within the
federal Department of National Health and
Welfare in Ottawa; this was the first such official
health promotion undertaking of this nature in the
world. The original Canadian venture was organ-
ized around the concept of lifestyle, with a focus
on areas such as smoking, alcohol and drugs, and
nutrition. Since then, a number of countries have
set up offices with the label health promotion on
them, and most of these acknowledge some debt
to the early Canadian model, at least to the extent
of their having basically adopted a lifestyle
approach to health promotion.
By the mid-1980s, however, it was clear that an
exclusively lifestyle approach to health promo-
tion was falling into increasing disfavour, partly
because it was considered too individualistic and
victim-blaming (Labonte & Penfold, 1981) and
partly because it had deflected attention from
another major element of the health field con-
ceptthe environment. In particular, both the
research literature and public sentiment support
the notion that the social environment is of critical
importance for health, both at an immediate
contextual level as exemplified by concepts such
as social support (Berkman & Syme, 1979), and
at broader societal levels such as general public
policy (Milio, 1981). This view has gained grow-
ing international acceptance, and its expression
may be seen in the Ottawa Conference and
Ottawa Charter of 1986, which relegated lifestyle
to a relatively minor role in the determination of
overall health status, and emphasized a range of
other social, political, economic and environ-
mental forces in health.
The site of the Ottawa Conference was no acci-
dent. Not only had Canadians been innovators in
the first period of health promotion, but for a year
or so prior to the 1986 Conference, the staff of the
Health Promotion Directorate had been working
on developing a new policy that attempted to
incorporate most of the main principles that were
being enunciated by the World Health Organiza-
tion (WHO) Regional Office for Europe, and that
appear in the Ottawa Charter for Health Promo-
tion. The Directorate was the first government
agency known to do this. This article is based on
that period of planning. Part of this process was
the production of a public discussion document
(Epp, 1986) somewhat akin to the earlier
Lalonde report. In the course of determining what
form this document should take, the question of
the current relevance of the health field concept
arose. The discussions raised fundamental issues
about the nature of health and health promotion
in the light of what is now known, and these were
impossible to resolve without a great deal of
further thought.
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Some of these issues are presented here, since
we believe they are of vital importance for future
conceptualization, practical action and research
in health promotion. We also attempt to show
how dealing with these issues could lead to an
expanded health field concept, the criterion for
which is its usefulness as both a conceptual and
pragmatic model for health promotion planning
and research.
Although we were both closely involved in the
discussions within the Directorate, the views
expressed here are entirely our own.
ISSUES AND DILEMMAS
By now, much has been written about the new
concepts of health promotion incorporated into
the Ottawa Charter by such sources as the WHO
Regional Office for Europe and Health promo-
tion. We do not wish to revisit this ground. But in
reappraising the health field concept, whose
beauty was its simplicity, we need to draw on
these and other sources to make our points, and
we find a number of issues, problems and
dilemmas.
The first question to be addressed is the
purpose served by a summary presentation such
as the health field concept. Its citation over the
years suggests that, at least in the past, the health
field concept has indeed served an important
function. What would this function be today? The
answer to this depends on the questioner's loca-
tion. For the present discussion, the assumed
context is a national or regional health agency
with an overview of thefield.Here, the health field
concept is used for three main reasons: to guide
policy, to argue for resources, and to provide an
analytical breakdown suitable for programme
development and research.

Input versus output
All three purposes listed above lead to the
question of what the output or product is. That is,
in today's market-oriented world, any develop-
ments or changes in policy, resource allocation or
programme implementation must have the com-
mon research goal of having to be justified in
terms of demonstrable results. What results are
sought? Excluding the question of saving money
(a doubtful argument anyway in health promo-
tion), what remains is an output somehow
expressed in terms of health status or quality of
life. On the other side of the equation is the input
to health status or quality of lifethat is, the
determinants of health, and the goals that might
be set in programmes to enhance health. In short,
any balanced view of a health field needs both
input and output specifications.
The original health field concept, however,
only seemed to refer to the input side of the
equation, as shown in the Lalonde (1974) report:
The Concept was designed with two aims in view: to
provide a greater understanding of what contributes to
sickness and death, and to facilitate the identification of
courses of action that might be taken to improve health.
This statement, however, gives some clue as to
outputit is health, defined in terms of sickness
and death. This view is confirmed by the last line
of a chapter discussing issues arising from the use
of the health field concept (Lalonde, 1974), which
states that "the ultimate goal is ... to increase the
average number of disability-free days in the lives
of Canadians". It is interesting, perhaps, that this
goal is not stated more explicitly in the report, and
may reflect a general disinclination in earlier
policy-makers to go too deeply into the issue of
output.
We strongly believe, however, that unless clear
and measurable goals are set, the best sounding
policies in the world have little credibility. Even
more important, the type of product conceived as
arising from particular policies will profoundly
affect the nature of such policies.
Therefore, it is necessary to be quite explicit
about the nature of the desired outcomes. In
short, any comprehensive health field concept
needs both input and output dimensions. To date,
however, most of the emphasis has been on the
input side alone.
Positive versus negative
Health outcomes can be defined either in negative
EXPANDED HEALTH FIELD CONCEPT 385
or positive terms. Negative definitions are
couched in terms of illness, death and disability
(or, more precisely, the absence or mitigation of
such things). A decreased or negative quantity of
the indicators, rather than the positive presence of
other indicators, provides the measures. The new
era of health promotion (post-Charter), however,
emphasizes positive definitions of health. The
Ottawa Charter for Health Promotion (1986)
defines health as: "a positive concept emphasizing
social and personal resources, as well as physical
capacities", and health promotion as: "the process
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of enabling people to increase control over, and to
improve, their health". The original health field
concept essentially used a negative definition of
health outcome, partly because it is easier to
measure illness, death and disability than health,
and partly because of its political appeal. But if the
health field concept is truly to reflect current
thinking, the definition of outcome should be
expanded to include positive measures. At
present, few such measures are universally
accepted.
Lifestyle versus social model
As mentioned, the aspect of the health field
concept that had the most impact on subsequent
health promotion policies was lifestyle, defined
by Lalonde (1974) as "the aggregation of
decisions by individuals which affect their health
and over which they more or less have control".
The concept is made even clearer in a later
chapter (Lalonde, 1974) on research:
Studies are needed to find out how Canadians can be
influenced to take more responsibility for the health of
their minds and bodies, and for reducing the risks which
they impose on themselves by neglecting important
lifestyle health factors.
The view taken by the Ottawa Charter is quite
different. It espouses a social model of health
promotion (as distinct from a lifestyle model), and
indeed, the word lifestyle is mentioned only once
in the Ottawa Charter for Health Promotion
(1986): "health promotion . . . goes beyond
healthy lifestyles to wellbeing". The Ottawa
Charter lists the fundamental conditions and
resources for health as "peace, shelter, education,
food, income, a stable ecosystem, sustainable
resources, social justice and equity". Health
promotion is seen not so much as a matter of
getting individuals to change their lifestyles as
requiring changes in society, in five broad areas:
386 J.MRAEBURNANDI.ROOTMAN
public policy, the overall physical and social
environment, the more immediate social environ-
ment at the community level, personal skills for
living, and health services.
In spite of the fact that lifestyle was the pre-
dominant legacy of the health field concept, the
concept itself put equal emphasis on four areas:
human biology, environment, lifestyle and the
health care system. In principle, the old health
field concept is not very different from the social
model concept of the Ottawa Charter, although
the latter represents a major change in emphasis
and language. The Ottawa Charter takes a more
holistic or ecological view, with the implication
that, in the areas in which the individual has more
or less control, the emphasis is on less rather than
more. Indeed, the view implicit in the Ottawa
Charter is that individuals have very little room to
manoeuvre in the context of the political, social
and cultural forces that operate on them. If this is
an accurate analysis, any new version of the health
field concept needs to take this into account
Health versus the quality of life
In the Canadian public pronouncements accom-
panying the development of the new policy, con-
siderable weight is put on the concept of quality of
life. Achieving health for all: a framework for
health promotion (Epp, 1986) states that
Today, we are working with a concept which portrays
health as a part of everyday living, an essential dimen-
sion of the quality of our lives. "Quality of life" in this
context implies the opportunity to make choices and to
gain satisfaction from living.
The Ottawa Charter for Health Promotion
(1986) also employs the expression: "Good
health is a major resource for social, economic
and personal development and an important
dimension of quality of life.".
It is generally conceded that the term quality of
life has multiple definitions (Krupinski, 1980).
Overall, it seems to refer to how good life is. In the
health area, it is used to refer both to input (as in
the nature of the society people live in) and output
(for example, in terms of life satisfaction or over-
all health status). It can also be defined both
objectively, by such social indicator measures as
employment, income and hospitalization (Kru-
pinski, 1980), and subjectively, by wellbeing and
satisfaction measures (Andrews & Withey, 1976;
Campbell et al., 1976). There can also be com-
binations of these things, such as perceived
quality of life in relation to determinants (Flana-
gan, 1982), and objective quality of life in relation
to such outcomes as hospital admissions or
disability-free days.
Such confusion may lead one to discard the
quality of life as a useful concept in policy or
research. The alternative is to make its dimen-
sions explicit, to show more precisely what it is. In
particular, specifications in the areas of input and
output and their subjective and objective aspects
seem to be necessary. A final problem remains:
the relationship of health to the quality of life. In
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broad terms, both the four dimensions of the
health field concept and the five of the Ottawa
Charter can be seen as equally determining health
and quality of life. That is, most of the sectors and
variables that affect healthsuch as government
policy, the quality of the environment, employ-
ment opportunities, housing, justice, community
integration and schoolingare also equally
determinants of quality of life, whether defined
objectively or subjectively.
Where, then, does health stop and quality of Me
start? Are they coterminous? If health is a dimen-
sion of quality of life (as the Ottawa Charter
states), what are the other dimensions? No certain
answers can be given to these questions at
present. Certainly, if health is being considered,
certain aspects of quality of life as input are more
relevant (as the health field concept recognizes in
including health care organization as a key
determinant of health, although it would probably
be excluded from a similar breakdown focused on
quality of life), but on the whole there is consider-
able overlap.
Subjective versus objective
In both a policy and research framework, the
usual goal is to obtain hard measures or variables;
objectivity is the accepted standard and subject-
ivity, suspect In moving away from the old
models, however, people must face the import-
ance of subjective aspects of health. Most studies
examining the relationships between input (such
as living conditions or social support) and health
finally arrive at the conclusion that how people
appraise or perceive input is more important than
the objective nature of the input (Krupinski,
1980; Lazarus & Folkman, 1984). With a
variable such as coping ability, perceived rather
than actual ability is related to health (Bandura,
1977; French et al., 1974). Again, on die output
side, the whole area of health policy and research

has been strongly led by the desire to show impact
in terms of hard indicators: typically disease,
death or other biomedical measures. But the
absence of disease is clearly less important to
most people than how they feel about their lives,
and research can often show a surprising lack of
correlation between hard health measures such as
disability or illness and self-reported health and
wellbeing. Undoubtedly there are difficulties in
subjective measurement, although some of these
may be more methodological than insurmount-
able (Krupinski, 1980). Regardless, the role of
subjective measures will be of increasing import-
ance if justice is to be done to the broad new
multidimensional approach to health heralded by
the Ottawa Charter.
TOWARDS AN EXPANDED HEALTH FIELD
CONCEPT?
The great merit of the health field concept was
that it provided the mandate to expand the
boundaries of the health field, as customarily
regarded by officialdom. The Ottawa Charter has
expanded that field even further. For this reason,
a simple conceptual model is still needed to
summarize graphically the complexity of this area
and to guide attention to the most important
aspects. We attempt to do this in the context of
objectives in policy, resource allocation, and
programme development and research.
If an expanded health field concept is to be
attempted, these issues suggest a number of
requirements for development beyond the
original concept
the inclusion of both input and output aspects
of the health field, with their positive and
negative, and objective and subjective aspects;
an emphasis on social and environmental
input, particularly the social environment as
such, but not to the exclusion of the concept of
lifestyle; and
the explicit determination of the relationship of
health to quality of life.
We attempt to develop an expanded health
field concept that incorporates these require-
ments. This is not a final version, but rather a draft
to stimulate discussion and modification. We
have taken the Ottawa Charter as our conceptual
guide; it is largely directed towards governments
and policy, and that is the setting in which the
EXPANDED HEALTH FIELD CONCEPT 387
expanded health field concept can best be
applied. To do this requires the following assump-
tions. On the output side, the definition of health
used in relation to health promotion in the Ottawa
Charter (as a resource, and as primarily positive)
is also the definition of most interest in measuring
the products of health systems. On the input side,
the five areas chosen as the focus for health
promotion action in the Ottawa Charter repres-
ent a consensus on the major determinants of
health from an action or planning perspective.
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Output
We believe, as both researchers and policy-
makers, that it makes sense to look first at the
output desired from any system. What is the
system trying to achieve? What are its goals? We
take into account the requirements hsted pre-
viously, plus the crucial requirement that output
must be measurable or quantifiable, plus a further
requirement of maximal simplicity. The output
necessary for an expanded health field concept
then falls into four categories:
Morbidity and mortality
There is no point in throwing the baby out with
the bathwater and rejecting the traditionally
negative and medical-model measures of morbid-
ity and mortality, providing they are kept in pro-
portion. Health, whether defined positively or
negatively, is obviously related to whether people
are sick or not, and it is appropriate to include
these measures, particularly as they are relatively
concrete and objective.
Positive health indicators
This is shakier ground, as no universally accepted
measures of good health, fitness or mental and
physical wellbeing appear to exist. There are
many indications of appropriate measures, how-
ever, and, in theory, there is no reason why even
quite objective measures of positive physical and
mental health cannot be developed and stand-
ardized. If credibility (and hence resources) is to
be given to a concept of health that goes beyond
morbidity and mortality measures, then clearly
this is an area for urgent research development.
Subjective perceptions
Positive health indicators, such as measures of
respiratory capacity, mental vigilance and loco-
motor agility, are seen as largely objective in
nature. People's subjective appraisals of their
388 J.M.RAEBURNANDI.ROOTMAN
physical, mental, social and overall conditions
include measures of expressed wellbeing, per-
sonal health status, satisfaction with life and
spiritual fulfilment. Although many such
measures are found in the literature, again it
would be desirable to move towards some univer-
sally acceptable indices, with due consideration to
the variety of cultural, social and physical dimen-
sions involved.
Functional capacity and coping
In the Ottawa Charter, health represents the over-
all energy level, capacity, coping ability and
stamina with which people deal effectively with
the demands of everyday life, once the limitations
caused by genetic endowment, permanent social
or personal handicap, or other chronic disability
or impairment are excluded. The Ottawa Charter
also comes down firmly on the side of an eco-
logical approach to health, and this category sees
health as the overall ability of people to cope with
the demands and exigencies of their everyday
ecospheres. There are no universally accepted
measures here, but, again, there is no theoretical
or technical reason why such measures could not
be readily available.
Determinants
On the input side, the four areas of the original
health field concept are replaced by the five
action areas of the Ottawa Charter, recast slightly
to be conceptualized as determinants.
Public policy
Public policy is the area in which action by
governments and others might best be taken to
alter positively the health outputs listed above.
Such policy can be seen at a variety of levels:
country, region, city, health authority, and institu-
tion. Of most interest are the broad policies for a
whole country or region. Two aspects of public
policy seem particularly important: monitoring
policies in a variety of sectors that are not
specifically related to health, to ensure that the
impact of these policies on health is recognized,
and if possible, altered to enhance rather than
harm health; and producing health policy that sets
up systems, services and mechanisms to allocate
resources that have health enhancement as their
explicit objective, rather than constructing ad hoc
policies in a vacuum. Overall, such policy
approaches demand a recognition of the eco-
logical nature of health determinantsthe fact
that many social, political, economic and other
factors affect health, not just health care services.
Society, culture and environment
This is the larger environment in which people
livethe broad political, institutional, economic
and physical contexts or ecospheres in which life
is lived out Changes are largely determined by
governments or planners. These areas are closely
associated with what happens in the policy arena,
but there is other input here, too, such as
decisions by corporations to institute certain
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industrial developments or such endeavours as
the WHO Healthy Cities project. Society refers
primarily to economics, industry, politics,
housing, social services and other areas directly
related to political and corporate decision-
making, and to socioeconomic and class factors
that need to be taken into account. Culture is the
enduring institutions, beliefs and ways of living
associated with identifiable larger groups of
people. In the health arena culture has special
importance when different ethnic groups live side
by side, often in a state of inequality or tension.
The term environment refers explicitly to the
physical environment, both natural and built, and
its health dimensions can range from concerns
with global pollution to house design or noise
levels. As mentioned previously, the concept of
environment was dealt with inadequately by the
Lalonde report. Doing it justice remains hard, but
both this determinant area and the next are
attempts to give environment the kind of weight
and meaning suggested by present knowledge
about the role of environmental factors in health.
Community and social support
This area also deals with environment (the social
environment), but at the level of people's more
immediate or intimate living environment, over
which they can or could exert a significant degree
of control. Research has clearly established that
the cohesiveness and supportiveness of the com-
munity, family, occupational and friendship social
systems in which people live have important
health-enhancing effects. The Ottawa Charter
adds the dimension of empowerment to these
findings; it is vital for health that people have
control over, and responsibility for, decisions and
factors that affect their health. Both organiza-
tional structures and resources are required to
make this possible. Governments, health services
and other relevant agencies need to make an

explicit effort to enable people to set their own
health priorities, and to take their own action both
individually and collectively, in the health areas in
which such action is appropriate. People's control
and ownership of their health-related endeavours
are crucial. This is an entirely new area for the
health field concept, but one that may come to
dominate all other efforts in the health field.
Personal behaviour and skills
Although the concepts of lifestyle and individual
behaviour change have fallen into some disrepute,
again, we believe it is important not to throw the
baby out with the bathwater. A reconsideration is
clearly needed, however, of behavioural changes
and the way these are conceptualized. This means
more than just individual changes in eating,
smoking, drinking, exercise, stress management
and sexual habits. We are looking at the overall
area of people's abilities and skills, in areas
directly related to health (such as learning self-
help medical skills), in broader self-development
areas (such as communication skills or parenting),
and in serf-esteem and areas generally related to
competence (such as overall educational attain-
ment). There is now strong evidence (Bandura,
1977) that self-esteem or self-efficacy is closely
related to health status, so this dimension is just as
important as changing personal lifestyle skills. In
practice, the most effective changes in behaviour
will be likely to occur in a social setting (such as a
club, self-help group, community centre or tribal
meeting house), so that the whole concept of indi-
vidual behaviour in this area is a relative one.
Nevertheless, it is important that health planners
take account of this area, and that resources and
systems be provided accordingly.
Health sendees
In the past, governments have acted as though
health services alone were the primary deter-
minants of health. Although this view is changing,
it is necessary to concede that, even in the most
Utopian of systems, these services will account for
the majority of health expenditure for the foresee-
able future. All systems evolve and are modified,
however, and one important way for this to
happen is to emphasize the new approach to
health presented in this article. Health services
are required to take a hard look at their object-
ives, which is not usually done in any meaningful
way.
This leads to the considerations of the appro-
EXPANDED HEALTH FIELD CONCEPT 389
priate evaluation of services. What are they trying
to achieve, and do they succeed? But typically,
evaluation of health services is absent or trivial, or
focuses simply on costs, so that out-of-date ser-
vices can often trundle on unchecked. Perhaps the
most important way health services can change is
to start training a new breed of professionals. If
health is largely determined by environmental,
social and personal coping factors, and the key to
improving health is the empowerment of people
to manage their own health destinies, then the
traditional training of health professionals runs
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counter to these forces in almost every respect,
and very often undermines them. New partner-
ships are needed between ordinary people and
professionals, so that each can use their own
strengths and expertise to enhance health. A
commitment is needed on the part of health
services to this approach, along with appropriate
training and retraining systems. To summarize: in
terms of resources, health services in some form
are likely to remain the focal determinant of
health for many years to come. It is hoped that the
kinds of horizons opened up by the Ottawa
Charter and an expanded healthfieldconcept will
begin to cast the operation of health services in a
different light, so that staff training, resource
allocation, construction programmes, and health
service planning will gradually adopt this new
perspective.
REPRESENTATION OF AN EXPANDED
HEALTH FIELD CONCEPT
Fig. 1 shows how all the elements discussed here
can be put together to make an expanded health
field concept. On the left is the input side: the
determinants of health, which essentially replace
the old health field concept. On the right is the
output side: measurable health outputs. These
components are contained within a overall frame
or field: the health field. The expanded health
field concept consists of both input and output,
and these are broken down to reflect the major
themes and areas currently considered relevant to
health planning and research, with major
guidance from the Ottawa Charter. The input
segments provide guidelines for planners when
changes or developments in health systems are
being contemplated. The output segments cover
the main dimensions of interest in any modern
view of the measurement of health status. The
390 J.M.RAEBURNANDLROOTMAN
HEALTH FIELD
Determinants
of health
1. Public policy
2.Society, culture
& environment
3.Community/socialsuppo
4. Personal behaviour/
skills
5. Health services
Fig. 1: An expanded healthfieldconcept
assumption is that constructive changes in any or
all of the input segments should result in positive
and measurable changes in any or all of the output
segments. If this happens, then there is at least
some basis for the conclusion that the action
taken was appropriate, a supposition that could
be tested further by controlled or quasi-experi-
mental trials using the same model. If no positive
changes are reflected on the output side, or if
these are of less than desired size or immediacy,
then the strategy was inappropriate, requires
more time, or needs modification. Although this
is common sense, we know of no generally avail-
able simple schema that is readily applicable to
most practical health planning situations, and, at
the same time, provides the data to determine
whether what is planned will actually work.
DISCUSSION
It is not possible to discuss all the ramifications
and possible shortcomings of what has been pre-
sented here. The expanded health field concept is
only a first attempt at a reformulation of the old
concept, and is offered for discussion and debate.
A few important issues, however, require some
comment.
Although it is possible to relate most of what
was in the original health field concept to the
expanded health field concept, the notable excep-
tion is what was called human biology in the
original (Lalonde, 1974).
This element includes the genetic inheritance of the
individual, the processes of maturation and aging, and
Measurable
health outputs
1. Morbidity/mortality
2.Positive health indicator
3.Subjective perceptions
4.Functional capacity
coping
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the many complex internal systems in the body... and
the things that can go wrong with it
This element does not appear in the expanded
health field concept for two reasons. One is that
human biology is a givenit is the basis on which
the other elements operate, and thus is qualitat-
ively different from the other elements. A second
reason for leaving this area out is that the
expanded health field concept deals with policy,
planning and research related to overall health
status, and interventions involving human biology
are most likely to come under the purview of
health services, which do appear in the concept
These comments suggest that the objectives of
the expanded health field concept may differ
somewhat from those of the concept, whose
objectives were (Lalonde, 1974): "to provide a
greater understanding of what contributes to sick-
ness and death, and to facilitate the identification
of courses of action that might be taken to
improve health", with the rider that "the Concept
is not an organizational framework for structur-
ing programs and activities". The expanded
health field concept has broadly the same thrust,
except that its aim is to provide a greater under-
standing of what contributes to overall health and
wellbeing, not just sickness and death. But the
attempt to provide a framework for assessing
whether action taken to improve health actually
has that effect is an entirely new objective of the
expanded health field concept. Indeed, the status
given to this evaluative or output aspect equals
that given to the determinative aspect. The health
field concept (Lalonde 1974) was concerned pri-
marily with providing "a sort of map of the health

territory" to "permit a quick location, in the
pattern, of almost any idea, problem or activity
related to health". The expanded health field
concept is explicitly designed for planning, policy
and research; the kind of breakdown it provides
could lead directly to suggestions for the alloca-
tion of resources to programme elements that
reflect fairly closely the elements of the expanded
health field concept, while at the same time pre-
serving the total holistic or ecological picture,
with appropriate integration and coordination
between the elements.
It could be argued that the expanded health
field concept as presented is too limited in its out-
put dimension by including only final or health
status outputs. A case can be made for the inclu-
sion of a circle intermediate to the input and out-
put circles of Fig. 1 that would make explicit the
role of process variables in health promotion,
particularly process output. For example, many
health promotion interventions are aimed at
changing attitudes, knowledge, structures or
policies, and changes in these process variables
also need to be measured as output. Although we
acknowledge the weight of this argument, we
believe the ultimate goal of any health promotion
endeavour is to affect health, and that process
variables are simply means to that end. In fact, a
lack of clarity about this issue may be one of the
factors that will impede the progress of health
promotion in the future, and the expanded health
field concept attempts to redirect attention to the
really fundamental issues. Nevertheless, we have
no objection to people adding a third circle, as
long as its input and output aspects are clearly
differentiated.
QUALITY OF LIFE FIELD
Determinants^
of quality of life
1. Public policy
'2.Society, culture
& environment
3.Community/social support,
Personal behaviour/
skills
5. Human services
Fig. 2: Possible quality of life field
EXPANDED HEALTH FIELD CONCEPT 391
Finally, the relationship between the expanded
health field concept and the concept of quality of
life deserves mention. Another article and a lot
more thought would be needed to do justice to it
Briefly, a quality of life field could be envisaged
(Fig. 2), very similar to the health field as defined
here. The quality of life field has specifiable input
and output that are potentially measurable, and
that in all probability would overlap substantially
with the elements of the health field.
It is likely, for example, that input to quality of
life would include elements of public policy,
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society, culture and environment, community and
social support and personal skills; although it is
unlikely that health services would be included,
human services might be. Further, it is likely that
health status would be one output component,
along with other elements such as the satisfaction
of economic and physical requirements and
social, spiritual and creative needs. The inclusion
of both objective and subjective aspects seems to
be essential in a quality of lifefieldas well as in the
health field. The health and quality of life fields
may be surmised to have much in common,
although they would differ in scope, emphasis and
content. Accordingly, the representation given in
Fig. 2 is extremely tentative.
CONCLUSION
The aim of this exercise was to take a new look at
the health field concept, in the light of the de-
velopments in health promotion represented by
recent initiatives in Canada and the Ottawa
Charter for Health Promotion, and to devise a
Measurable
QOL outputs
n.Objective indicators of>
"quality society"includin
positive health indicators
2.Subjectively expressed
overall life satisfaction
including perceived
health & wellbeing
392 J. M. RAEBURN AND I. ROOTMAN
schema that can be of practical use to planners,
policy-makers and researchers. A number of
requirements were listed, and we believe that the
expanded health field concept presented here
meets them. We want to stimulate discussion and
debate in this area, with the hope of creating a
conceptual system that can achieve international
consensus and applicability, to guide the work of
many of us in diverse settings, and to build on the
directions outlined in the Ottawa Charter.
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