"Health promotion...is the process of enabling people to increase control over, and to improve, their health by developing personal skills, embracing community action, and fostering appropriate public policies, health services and supportive environments. Health promotion represents a comprehensive social and political process, embracing actions directed at strengthening the skills and capabilities of individuals, families and communities and changing social, environmental and economic conditions to alleviate their impact on public and individual health." - Ottawa Charter for Health Promotion (World Health Organization)

Emerging from the above-quoted framework, this 92-page report explores experiences in Europe and Eurasia (E&E) with motivating health care consumers to take more responsibility for their health. The United States Agency for International Development (USAID) Bureau for E&E undertook this investigation within the context of its Communication for Change (C-Change) programme, which supports a systems approach to shifting individual behaviours and social norms in an effort to achieve long-term change. The rationale is that this type of approach might cohere particularly well in a region where it is not infectious diseases that are of growing concern but, rather, chronic (noncommunicable) illnesses such as diabetes, cancer, and heart disease. These illnesses are frequently related to lifestyle choices such as alcohol, smoking, physical activity, and diet - choices that may be impacted by social norms, social networks, and social systems.

This assessment focused on Kyrgyzstan, Albania, and Armenia, and consisted of 4 components: a literature review of the state of health promotion and primary health care; pre-assessment surveys and conference calls with USAID missions; country visits to conduct in-depth interviews and to visit active USAID-funded projects and health facilities in rural sites; and focus groups with health consumers in each country.

Some of the areas of concern identified through this investigation include:

• In general, especially in areas where USAID-funded projects are not underway, health consumers lack "power" in terms of their own health care, the services rendered to them in public facilities, and in the basic doctor-patient relationship.
• Consumers generally feel negatively about the care they receive in public clinics, reporting that they do not trust the skills of providers and they feel service quality is poor.
• Donors have been addressing important health issues in the region through awareness campaigns (e.g., public information efforts in the media). However, traditionally, these efforts tend to be focused on particular disease topics (e.g., HIV and AIDS or tuberculosis - TB) or a calendar of monthly health issues.
• Currently, there are no sustained efforts that address the long-term health issues related to chronic diseases, which are the health issues affecting most consumers in this region.
• Although government institutions are making efforts to address health promotion and disease prevention, resources and staffing are limited.

Reasons for optimism include:

• Consumers are interested in preventive health and eager for information. Consumers typically obtain health information from their providers (both public and private), or from television and newspapers.
• Efforts in the region are growing to empower health care consumers. These programmes typically involve international non-governmental organisations (NGOs) in partnership with local groups, such as community-based volunteer health groups working to motivate consumers to participate in health planning and decision-making in their communities. Several civil society organisations (CSOs) are starting to promote patient rights, patient information, and consumer protection, aided by new legislation on public health.
• Consumers are reacting positively to these interventions, but more needs to be done.

In light of the above, C-Change recommends working with governments to develop an overarching health promotion strategy that is based on behavioural research and the epidemiology of each country. Affecting behaviours related to chronic disease requires a long-term commitment to interventions that address the individual, the community, and decision-makers, as well as laws and policies related to high-risk behaviours. This strategy centres around a commitment to supporting individual behaviour change related to healthy lifestyles by creating a conducive environment that reinforces the change through structures, programmes, and policies. Thus, multidimensional interventions are needed to initiate and sustain empowered health care consumers and more effectively address chronic diseases.

To facilitate this process, the document provides specific recommendations for each of the following areas: governments, health care providers and pharmacists, communities, the private sector, the media, civil society, and research. For example, with regard to the media, C-Change indicates that "[t]raining journalists on health-related issues and providing them with opportunities to speak with those involved in local initiatives helps to foster long-term relationships with the press and ensures increased coverage and more accurate reporting." Other suggestions offered here to support behaviour change communication (BCC) messaging in the media include identifying and training Ministry of Health (MoH) media spokespersons, working with advertising and marketing agencies to improve BCC programming, engaging university communication departments to strengthen in-country capacity for health journalism, and developing television formats that engage, educate, and activate health care consumers to take responsibility for their own and their families' health.

C-Change website.