Health Promotion In Reproductive Health: Emphasis Emphasis on Family Planning

HEALTH PROMOTION AND SOCIAL MARKETING

Health Promotion In Reproductive Health:

Emphasis Emphasis on Family Planning

28th July 2011

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Abstract

Health promotion represents a comprehensive social and political process aimed at improving

health. Family planning has been a very important tool in promoting reproductive health. It

employs most approaches of health promotion as well as good social marketing in achieving its

aim. However, the ability to link between the theory and practise of health promotion is still

gray in reproductive health, but has not hindered the continuous use of health promotion

strategy in this field as in other fields of public health. To properly delineate the practise of

health promotion, simple but comprehensive and consensus conceptualisation as well as an

adaptable frame work for practise should be provided.

Health Promotion In Reproductive Health: Emphasis

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For decades now, it has been difficult to reach a consensus on an

all encompassing definition for health. Although, the WHO definition

of health as a ‘state of physical, social and mental wellbeing, not

just the absence of disease’ has been critiqued for not being

completely definitive, a more encompassing definition is still being

awaited. Considering the difficulties in defining health, one

wonders what the term health promotion means, seeing that we do not

entirely know what is being promoted. Health promotion, a novel

development in the field of health care, has been defined or

explained by various authorities in diverse ways. These numerous

definitions portray the ambiguity thrust on the subject by its

nomenclature as well as the difficulties experienced by health

practitioners in adapting to the roles required of them in promoting

health. In deconstructing this terminology, the following

definitions/ explanations have been proffered –

‘Health promotion represents a comprehensive social and political

process. It not only embraces actions directed at strengthening

skills and capabilities of individuals, but also actions directed

towards changing social, environmental and economic conditions so as

to alleviate their impact on public and individual health. Health

promotion is the process of enabling people take control over the

determinants of their health and thereby improving their health’

(Nutbeam, 1998)

Other explanations include those from the department of health,

Welsh Assembly, 2005, which defines health promotion as the ‘field

of activity that includes supporting people to develop personal

health skills, fostering public participation, building

partnerships, coordinating policy and strategy’. Following the birth

of health promotion by the Ottawa Charter in 1986, three key terms

are underlying in the understanding of health promotion – Enabling,

Advocating and Mediating (Naidoo and Wills, 2009)


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Health promotion as a discipline has an aim, to improve health or to

facilitate actions towards improvement of health. Considering the

diverse definitions of health, both collectively as societies and as

individuals, then the work of health promotion would require

enormous skills on the part of the practitioner in planning and

executing health-promoting activities as the overall goal – health,

would mean different things to different people and groups. Another

aspect to consider in this discourse on health promotion is the

question - what is not health promotion? Could all activities aimed

at improving health be seen as health promotion, including Curative

Medicine? Considering that, Curative Medicine could enable

individuals promote their health, by placing them in a better

position to appreciate healthy choices as well as restore them to a

position in which they can take control over the determinants of

health. Bearing this analogy in mind, it then makes it difficult in

practise, to draw a line as to what is health promotion and what is

not.

The other point to consider in this discourse is what works in

health promotion. This thought arises on the premise that every

individual choice may not necessarily result from one intervention

or information. Following the previous analogy, these ‘cured’

patients, may make better health choices, not just as a result of

the illness experience, but also as a result of health education,

and perhaps imposing government regulations and policies. Hence,

evaluating which intervention really produced the desired change

becomes difficult. This then explains why in various activities

aimed at promoting health, almost all approaches are employed in

order to effect the required change. Due to this difficulty in

evaluation, in practise, health promotion has rigorously focussed on

physical and in some part social wellbeing. Like the topic of focus,

Reproductive health with emphasis on family planning, applies an


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appreciable range of health promotion concepts in ensuring safe and

enjoyable motherhood through family planning, and measure their

effectiveness through uptake and use of medical products and

services.

Reproductive health is defined as the ‘state of physical, social and

mental wellbeing in all matters relating to the reproductive system

at all stages of life’ by the Illinois Department of Health Care and

Family services. The definition is flawed by the confinement of this

wellbeing to the reproductive system, which depicts a focus on the

physical wellbeing, and this really portrays exactly what is done in

most cases of reproductive health promotion. Another definition

would be that proposed by WHO (2011a), which states that

‘ Reproductive health implies that people are able to have a

responsible, satisfying and safe sex life and that they have the

capability to have children and the freedom to decide if, when and

how often to do so’. This definition makes a distinction between

sexual health and reproductive health. The social and emotional

aspect of health is covered by the definition of sexual health. This

is defined as the ‘enhancement of life and personal relationship not

merely counselling and care relating to procreation and sexually

transmitted diseases’. To achieve these objectives, various

modalities such as the use of legislations, improving maternal

services as well as family planning, have been employed with varying

success rates.

However, UNFPA noted that one-fifth of the worldwide disease burden

is contributed by reproductive health and a third of all mortality

and morbidity in women of childbearing age. Hence, in a statement by

UNFPA, on improving reproductive health, key elements were

identified. These elements are – every child is wanted, every birth


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is safe, every young person is free of HIV/AIDS, and every

girl/woman is treated with dignity and respect. In ensuring these

elements, the role of family planning cannot be overemphasized. WHO,

Illinois Healthy Women by Illinios State, USA, The Adolescent

Project in Rivers State, Nigeria and several other authorities all

over the world have used this tool of health promotion alongside

with other programmes such as Safe Motherhood Initiative to ensure a

better reproductive health. Family Planning is a process that

enables individuals or couples, anticipate, space or control

childbirth, using contraceptives or by treating infertility (WHO,

2011b). It employs various approaches of health promotion and social

marketing in achieving its goals and objectives, which presently is

Universal Coverage and Access by 2015 in all member states of the

World Health Organisation.

In the science of health promotion, various approaches as well as

models have been explained. The approaches include Medical, Health

Education, Behaviour Change, Empowerment and Social Change (Naidoo

and Wills, 2009). The first approach the medical approach is a very

old one with three levels of prevention – primary, secondary and

tertiary (Gillam, 2006). Family planning could be seen as a primary

form of prevention as well as secondary. In some way it could also

be used as a tertiary mode of prevention, to reduce maternal

mortality in grand multiparous women. The Medical approach

identifies those at risk, just as the family planning method at its

inception targeted women and adolescent girls. Albeit, with recent

findings of unmet needs, men were included as a target group as well

(UNFPA, 2004). This already depicts a flaw in this model, as it

shows that a target or at risk group does not exist in isolation,

there is some form of interconnectedness in the society. So

focussing on an at risk group alone, may not resolve the issues as

we now know that the determinants of health are diverse and


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connected. However, in the face of scarce resources, identifying an

at risk group is relevant and cost effective in tailoring programmes

and would also facilitate the inclusion of other determinants which

may have been overlooked at first. In the implementation of family

planning, the medical approach was very paramount, it involved

primary health care consultations with an expert - a trained public

health officer in family planning, the client in some instance were

passive, as the types of contraception available were already drawn

and fixed. In fact, the option was contraception or no

contraception; there was no room for formulation of ideas by the

client. This is to be expected in medical and scientific situations,

requiring very great care and expertise. It was then easy to

evaluate based on uptake of the contraceptives and child birth

rates. Nevertheless, this could not preclude the fact that other

determining influences such as the prevailing economic

circumstances, changing societal norms and values and environmental

pollution, may have been responsible in part for declining birth

rates. Studies have shown that this approach to health promotion is

usually beneficial to those who are already enlightened and would

normally have made the choice (Taylor and Field, 2003).

The second approach is Health Education. This involves an organised

transfer of health knowledge to improve health literacy and

beneficial life skills (Nutbeam, 1998). It may or may not identify

an at risk population and is usually expert led. An example of this

in family planning, include the family planning information leaflets

and talks given during antenatal classes. The group usually in sub-

Saharan Africa is a heterogeneous one, with first time mothers, as

well as older mothers. The family planning methods are taught on the

assumption that knowledge transcribes to practise. Other

determinants of health such as the acceptance of the methods by the

woman’s family particularly her husband, the cost, the ability to be


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consistent as well as her present state of mind are ignored and

these accounts for the unmet needs of family planning.

Notwithstanding, knowledge gained through health education, cannot

be discounted as not leading to some form of health gains. The

cognitive theory of learning, states that learning involves

cognition, affection and behaviour (Miller and Dollard 1941). In as

much as the behaviour change, in this respect better health may be

difficult to measure, the cognitive level before and after the

transfer of information is easily evaluated and the affective aspect

of education could be explored in some way. Health education is also

expert-led and may or may not give room for individuals to negotiate

or contribute to the expected outcome (Naido and Wills, 1994). One

of the benefits of this approach is that information could be

disseminated quickly, using various means. The other side to this

could be the tendency to be misinformed or for the message to be

misunderstood. For example the use of radio jingles and billboards

to encourage family planning, putting up some health education

information, have a very wide coverage and greater appeal (Salem et

al 2008). However the information may not be properly spelt out due

to time or space constraints and may be out rightly wrong. The use

of school curriculum or school based programme in health education

in reproductive health especially prevention of unwanted pregnancies

in adolescent have been extensively researched, with mixed outcomes

and little or no long term gains (Bennett and Assefi 2003, DiCenso

et al 2002). In all, health education does not guarantee a change in

behaviour and should be used in addition to other health promotion

strategies.

The third approach to health promotion, involves some form of

persuasion, and is based on the assumption that individuals are

responsible for their health and have the ability to choose

healthier lifestyles. As asserted by Bandura, (1994) the quality of


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life is greatly influenced by life style, hence individuals have the

ability to wield some level of control over their lives. This

approach is the Behaviour Change approach. Several models or

theories have been described, and these include Health Belief Model,

Health Action Model, Stages of Change Model, Social Learning Theory

and Theory of Reasoned Action (Baum, 2008). This approach in family

planning has been employed in some ways. One example is the use of

model families (a successful, healthy and well-spaced family) in a

community to illustrate the benefits of family planning; this is in

line with the theory of Social Learning. This method would also

include the provision of the required contraceptives and a continued

support group. In practise, this approach for family planning may

not always be feasible, except there is an established group, for

example a book readers club or gardening club. The other factors

that may adversely affect this approach would include the belief

systems of the people and the possible exclusion of relevant

decision makers such as the husbands in such groups. Family planning

decisions in most society is a collective decision between partners,

which could change with changing circumstances. Another example of

the use of behaviour change approach was the Conditional Cash

Transfer Approach, which when evaluated was found to have mixed

benefits (Signorini and Queiro, 2009; Steele et al 2001). Hence, the

behaviour change approach though very effective in certain life

style illness and problems of addiction, may not be very effective

in family planning. However, in the World Health Organisation’s four

cornerstones of family planning guidance, the 3rd cornerstone –

Decision making tools for family planning clients and providers,

could be seen as a health education approach, as well as exhibiting

some level of health belief model. These cornerstones are in

acknowledgement of the fact that people come for family planning

with a method already in mind but they need to do some cost-benefit

analysis to finally make an informed decision (WHO and JHSP, 2008).


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The next approach in health promotion is the Empowerment Approach.

This approach has been associated with the Rogerian Theory, which

considers the human-environment approach and the unitary theory

(Shearer 2004). In this approach, one of the key terms in the

definition of health promotion is actively employed – enable. It is

usually client led with the health promoter being a facilitator.

This could be employed in promoting health for an individual, as

well as in a community. It echo’s a particular phrase in the Ottawa

Charter (1986) – ‘enabling people to increase control’. It considers

the two aspects to family planning critically – the supply of the

family planning services to meet the demand and the creation of

demand. In a study of family planning interventions between 1995 to

2008, by Mwaikambo et al (2011), it was observed that both the

demand and supply interventions, recorded appreciable improvement in

knowledge, attitudes and practise. They advocated for a combination

of several approaches including community participation as

prerequisite to achieve the full benefits of family planning. This

can be achieved effectively by the use of the empowerment approach.

However, it has been argued that the effect of the empowerment

approach is under evaluated and its direct effect on health is

poorly understood (South and Woodall, 2010). Like other approaches

in health promotion, empowerment approach would be highly effective

when used in combination with other approaches, as well as good

social marketing.

Since by default the client locates the felt needs, it enables the

health promoter to channel resources effectively and would be most

appropriate in actualising the goals of universal coverage in family

planning. The pitfall to this approach would include the time spent

in seeking community participation, wrongly identified needs or

identification of needs remotely related to the goals of the health

promoter or sponsor organisation. However, studies by Aoujoulat et


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al (2007), suggested that for empowerment to be true to its

definitions, then there should be no predefined goals and objects by

health providers. This point in some way could be argued as being

followed in family planning, as the goal of universal coverage, does

not undermine the individual needs or objectives in procuring family

planning. For instance, there is no set target for the number of

children each society or family is entitled to but at the same time

an ideal number may be inadvertently suggested, hence undermining

the principles of empowerment. Then if the principles of empowerment

do not encourage setting of objectives by health providers, then by

its very own design and construct, it would be difficult to evaluate

as every individual would have a different goal. Hence it could also

defeat the aims of health promotion, as some individual goals may

not necessary lead to health (health as defined by the individual

and/or the provider). In addition, it is worth noting that family

planning is also seen as a tool for empowerment in sexual and

reproductive health (WHO, 2011c).

The fifth approach to health promotion is the Social Change

approach. It is a top down approach involving social regulations

aimed at addressing health inequalities. This approach is much

evident in the actions of WHO member states and participants in the

ICPD conference in 2004 towards family planning (UNFPA, 2004). The

paper found that from 1994 to the date of its publications, 46

countries had enacted laws expanding access to reproductive health

services. Furthermore, there were increases in the supply of

contraceptive as a way of meeting the unmet needs. An example of

such laws was the removal of husband consent for administration of

contraceptive in Papua, New Guinea (UNFPA, 2004). The role of the

health promoter in this approach is usually that of advocacy and

mediation. It requires skills in addressing the other P of social

marketing – policy/politics. On the surface, may look relatively


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easy, but in reality is very tough and may raise a myriad of ethical

concerns. The issue of instituting policies and guidelines may be

infringing in some way on an individual’s autonomy. However the

ethical principle of beneficence is also considered in creating a

balance during policy and decision making. The processes involved in

getting the appropriate authorities to issue such policies are

usually rigorous and may require community participation through

community empowerment. This still points to the interrelatedness of

the various approaches to health promotion. In the use of social

change in encouraging family planning, improvement of reproductive

health services, increase in the supply of required contraceptives

and skilful manpower are equally relevant. This approach to health

promotion is linked with settings based health promotion in which

activities of health promotion are tailored to suit the setting such

as school, workplace, and community. In a review by Whitelaw et al

(2001), they identified that though this settings based approach was

viewed with optimism as a means of reducing inequalities however,

inequalities still persist and might even be created by certain

policies. More so, making policies without address the health needs

of the people and creating awareness to the health needs being

addressed may achieve little or no health gain. Hence the need to

employ all approaches effectively with good social marketing skills

in order to achieve health for all.

In achieving a holistic approach to health promotion, several models

have been formulated, to serve as a conceptual framework for

practise (Naidoo and Wills 1994). These models though useful in

producing theoretical bases for practise are riddled with confusing

terminologies, but have a reasonable level of similarity (Naidoo and

wills 2009). Four models have been described by Naidoo and Wills,

(2009). These models are Caplan and Holland (1990), Beatie (1991),


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Tannahill (Downie et al, 1996) and Tones (Tones and Tilford, 2001).

Below are some diagrammatic representations of the models –

Beattie (1991)

Tannahill’s Model (Tannahill,

2009)


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Tones and Tilford (2001)

Caplan and Holland Model (Naidoo and Wills, 2009)

These models aim to improve the practise of health promotion, by

creating a sustainable template for action, thereby allowing

professional to act more objectively and not based on immediate

demands. However, the debate and lack of consensus in this area of

health promotion, makes it impossible to adopt a universal approach

or model. The Tones and Tilford model could be descriptive of the

family planning model. Other integrative models have also been

proffered. Below is an example:


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As earlier stated in addition to models and approaches to health

promotion, good social marketing scheme is relevant in actualising

the aims of Reproductive health. Social Marketing has been defined

by Turning Point as ‘the use of marketing principles to influence

human behaviour in order to improve health or benefit society’. This

definition raises some ethical concerns – Are we manipulating our

clients, even though the benefits are noble? Who defines what is

right for an individual? Nonetheless, social marketing has been

employed extensively in family planning and reproductive health. It

has been used in addressing both the demand and supply aspect of

family planning. Although, Karl Hoffman of Population Service

International in 2010, stated that the demand end for reproductive

health products particularly family planning products and services

were natural instincts to the women, while social marketing was

crucial in addressing the supply end. However, social marketing has

also played important roles in creating awareness, hence improving

demand for these products and services. Unlike health promotion,

social marketing does not consider community participation in


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programme planning, but aims at passing a message to the target

audience (Erben et al, 2000). Most of the social marketing

strategies employ routine means of communication, such as mass media

– radio, television, billboards and flyers as well as traditional

outlets for provision of goods and services. They also employ non

traditional means such as concerts, workshops and games. UNAIDS has

identified possible models in which social marketing products can be

distributed. These models include community based distribution,

which has been used extensively in family planning; manufacturers

model, which subsidises the cost of manufacturing the product and

targeted service delivery which is also being employed to meet the

unmet needs of family planning, by targeting under-served groups.

Irrespective of the strategy of communication and distribution, the

4 P’s of social marketing are always considered.

The impact of these strategies, vary from country to country and

amongst groups within a country. For instance in Zambia, in a review

of social marketing strategies in reproductive health, by Rossem and

Meekers, (2009), it was found that those with the highest exposure

to social marketing campaigns (which mainly radio and television

programmes and adverts) on the use of condom had a higher rate of

use. It was also noticed that radio programmes had a wider coverage

than television programmes. Similar effect was noticed in the

Sacramento (USA) Prevention Marketing Initiative on increasing

condom use (Turning Point, 2003). In this programme radio, print

ads, branded condoms informational lines and workshops were

employed. It is worth noting that though both programmes had the

similar aims, and applied social marketing principles, but there

were differences in their methodology. These differences exist

because of the local context and socio economic situations – Zambia,

a developing country and United States of America, a developed

country. However, in Meekers and Rahaim (2005) Five hundred and


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fifty-five (555) years evaluation of social marketing programme, it

was noted that in as much as the socioeconomic factor plays an

important role in the effectiveness of a social marketing programme,

of equal importance are the programme maturity and size of target

group. Generally, for an effective social marketing programme in

addition to the aforementioned points, flexibility at every point

from planning to implementation is important as well as covering the

two main aspects, which is making the product or service available

and encouraging people to use it (UNAIDS, 2000).

In conclusion, health promotion in reproductive health is an all

encompassing field which is ongoing and dynamic. It requires a

highly level of skilfulness on the part of the health promoter in

actualising the goals and objectives of family planning. Unlike some

other health promoting activities that may focus on creating

awareness on health issues and encouraging behaviour change, health

promotion in reproductive health goes beyond that to supply the

required goods and services to meet the present demand and future

demands. Hence it creates a demand and also supplies the demand. It

also requires flexibility and focus on the part of the health

promoter as different settings, countries and cultures have diverse

reproductive health needs. Also, within a ‘homogenous’ group, the

individual health needs still vary. It entails the use of adaptable,

simple and holistic frame works to achieve these goals. The work of

health promotion is developing theoretically, but has been practised

in times past (Green and Tones, 1999). The Ottawa charter by the

World Health Organisation (WHO) was a major tool that brought about

context such as settings, socioeconomic environment and policies;

and not just individualism to health and in turn brought about a

holistic approach to health promotion (Kickbusch, 2003). However, it

has been noted by Irvine (2007), that the traditional concepts of

health promotion are still prevalent in practise. This charter is


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also a health promoting tool as it mediates and advocates towards

the actualisation of health for all. It also serves as a policy tool

and has led to changes in various member states. Finally, health

promotion and social marketing are important concepts, with overlaps

in activities and objectives. Social marketing could be seen as a

tool in health promotion or health promotion an aspect of social

marketing. This dilemma would persist seeing that these concepts

were in practise prior to their conceptualisation. However, in as

much these conceptualisations are of import to the academician, to

the field worker, the aim is to apply which ever principle that

works in actualising health for all and in this context reproductive

health for all whilst bridging the gap between theory and practise

(Best et al, 2003).

Word count: 4137 words (excluding diagrams and Abstract)

Abstract: 109 words


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Documents

Health Promotion In Reproductive Health: Emphasis Emphasis on Family Planning