Department of Public HealthUniversity of Aberdeen

Health Promotion: Principles, Values and Definitions

Flora Douglas 2008HE 3514 and HE4509

Intended learning outcomes

Outline the basis for health promotion as an area of public health policy and practice.

Be aware of the main aims, values and principles of health promotion as described by the Ottawa Charter, as a socio-ecological approach to population health improvement.

Intended learning outcomes

Outline and critically discuss five approaches to health promotion identified from the literature describing contemporary UK health promotion policy and practice.

Why health promotion?

Health Promotion

What is it?

Health Promotion Origins

• Improving the health of individuals, communities and populations is a long standing societal issue.

• First legislative action re health improvement went beyond the individual and sought to address the socio-economic conditions that people found themselves in. (1796)

•Focus of this health improvement

effort has shifted from

environments, systems and

populations to individual based

approaches and back again.

20th Century focus on the individual

• The focus on wider determinants of health, and actions on environmental variables within public health shifted towards more individualistic approaches (focused on biology and behaviour) round about the 1870s.

• During this time ideas about germ theory and micro-causality took hold, and attention was directed towards the role of immunisation and vaccination in improving health (Ashton, J. 1988)

20th Century focus on the individual (contd)

• Decline in infectious disease rates, and the emergence diseases linked to unhealthy ‘lifestyles’ such as coronary heart disease and cancer, also supported this change in public health focus.

• Increasingly, chronic diseases were viewed as being created in parted by the individual behavior and life style choices, and subsequently efforts to encourage individuals to make lifestyle changes became a key focus of public health work.

The rise and fall of health education?

• Health education - defined ‘as planned learning experiences to facilitate voluntary change in behaviour to develop consciously pursued health-directed behaviour’.

• Emerged as a discipline within public health movement during the late 1800s, early 1900s - primary aim concerned with encouraging behavioural change.

• The emergence of health education is often linked to the rise of the temperance movement in the UK.

• Mass health education programme to deal with 1st World War soldiers returning home with some form of venereal disease (20%).

Limitations of health education

• However evidence indicated that health-related behaviour and individuals’ are not just isolated acts, always under the autonomous control of the individual, but are socially conditioned, culturally embedded and economically determined.

• Health behaviour and lifestyles regard it as a combination of social and cultural circumstances that shape and restrict behaviour, as well as the personal decisions that one might make about in choosing one behaviour over another.

Implications

• Attempts to change behaviour needed to take account of cultural values, and, the economic and environmental circumstances surrounding and supporting the targeted lifestyle change.

• This more holistic view of lifestyle justified a more holistic approach to promoting the health of individuals and communities, (Tones, K. 200)

Emergence of New Public Health - 1970s

Key drivers• A general, trans-national reappraisal of health care priorities

– rising health care costs

– an apparently limitless demand for healthcare

– a rapid growth in the elderly proportion.• Emerging critiques of the role and effectiveness of medicine

versus social and environmental changes in population health gain (McKeown 1976, llich, 1977)

• The emergence of feminist ideas about gaining more control over health care decisions, and self-help groups in general.

• Concomitant rise in other similar movements such as community development, communications and consumerism movements.

Contemporary Health Promotion Origins

1. World Health Organisation (WHO) Declaration of Alma Ata (Russia) 1978

– Improvements in health could not be determined by investments in the health care systems alone – prevailing view since the end of the 2nd WW.

– Needed to enrol other sectors in health improvement efforts

2. Canadian Lalonde Report (1974) 3. Global Strategy for Health for All by the Year 2000

(WHO 1981)4. Health Promotion: Concepts and Principles (WHO,

1984)5. Ottawa Charter for Health Promotion (1986)

Definitions

“Health promotion is the process of enabling people to increase control over and to improve their health. …. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to

well-being.” Ottawa Charter for Health Promotion (1986)

Implications?

• Ottawa Charter health promotion = radical social change.

• Enabling individuals to increase control over the determinants of their health (or disease) means challenging the status quo (accepted ways of doing things – existing vested interests) at an individual and collective level (community/society).

• Health promotion happens within & out with the health sector.

5 Health Promotion Actions

• Developing public policy.

• Developing personal skills.

• Strengthening community action.

•Creating supportive environments.

•Reorienting health services

Pre-requisites for health

• Peace• Shelter• Education• Food• Income• A stable eco-system• Sustainable resources• Social justice and equity

Health promotion’s founding principles

• Concerned for the population as a whole, in the context of everyday life, rather than just focusing on those at risk from specific disease.

• Is directed at the causes or determinants of health to ensure that the total environment, beyond the control of the individual, is favorable to health.

Health promotion’s founding principles

• Uses a combination of methods and approaches communication, education, legislation, fiscal measures, organisational change, community development and supportive of emergent local developed health initiatives.

• Aimed at effective public participation by encouraging people to find their own ways of managing health in their communities.

• An activity in the health and social fields and not a medical service. Looks to health professionals in primary care as having a role in nurturing and enabling health promotion.

World

Health Organisation 1977

Health Promotion Policy Update

• Bangkok Charter for “Health Promotion in a Globalised World” World Health Organisation 2005 (6th Global health promotion

conference).

• Health promotion should be:– Central to the global development agenda– Core responsibility of all governments– Key focus of communities and civil societies– A requirement of good corporate practice.

5 approaches to health promotion

1. Medical or preventive2. Behaviour change3. Educational4. Empowerment5. Social change

Naidoo and Wills (2000)

Main objectives of health promotion

To prevent disease (Medical or Preventive) To ensure people are well informed and able to

make “healthy” choices (Behaviour Change and Educational)

To help people to acquire the skills and confidence to take greater control over their health (Education and Empowerment)

To change policies and environments in order to facilitate healthy choices (Empowerment and Social Change).

1. Medical or Preventive Approach

• This approach is aimed at reducing premature deaths (mortality) and avoidable diseases (morbidity).

• Actions are targeted at whole populations (eg. immunisation) or so called high risk groups.

• Some argue this approach seeks to increase the use of medical interventions to promote health.

1. Medical or Preventive Approach

Primary prevention – prevention of the onset of disease through risk education. – smoking cessation, cholesterol reduction.

Secondary prevention – preventing the progression of disease – screening and other methods of early diagnosis.

Tertiary prevention – reducing further disability or, preventing the recurrence of illness, patient education, palliative care.

1. Medical or Preventive Approach: Characteristics

Is popular as it has high status, using scientific methods – epidemiology.

In the short term, this approach is cheaper than the treatment of people who have become ill. (May not be the case in the longer term as people live longer and suffer from degenerative disease).

It is top down and expert led, medical and health professionals and recognised as having expert status.

2.Behaviour Change Approach

This approach aims to encourage individuals to adopt “healthy” behaviours that are regarded as key to improving health.

This approach is popular - views health as the property of the individual.

2. Behaviour Change Approach

AssumptionsPeople can make real improvements

to their health by changing their lifestyle.

If people don’t take responsibility for their actions they are to blame for the consequences -victim blaming approach.

2. Behaviour Change Approach However, it has become

acknowledged that the complex relationship exists between individual behaviour, social and environmental factors.

Behaviour - it is now recognised may be a response to the conditions people live in and the causes of these conditions may be outwith individual control.

But - the behaviour changeapproach remains popular with health promotion agencies!

Media and behaviour change.Pause for thought!!

One of strategies used to encourage behaviour change (and popular with health promotion agencies) is the use of multi media campaigns.

Can you think of any mass media campaigns that you have noticed that have been concerned with encouraging behaviour change?

3. Educational Approach

• Strongly linked to health education

• Seeks to provide knowledge and information, and to develop the necessary skills so that people can make informed decisions about their behaviour.

3. Educational Approach

Assumption• Increasing knowledge may change in

attitudes, that may result in changed behaviour.

• It is argued that this approach does not necessarily set out to persuade or motivate change in a specific direction!

4. Empowerment Approach

• So-called bottom up approach - idea is premised on

helping people or communities to identify their own health

concerns, gain the skills and make changes to their lives

accordingly .

• This approach is considered by many to reflect most

faithfully the general principles of the Ottawa Charter

definition.

• Professional acts as a facilitator rather than expert – as a

catalyst for change – by supporting individuals and

communities to make or lobby for changes.

4. Empowerment Approach

• Approach described as a way of working which increases

people’s ability to change their social reality.

• Community development is a similar way of working, in that

CD professionals are concerned with the helping

communities to identify general/social concerns and work

with those communities to plan a programme of action to

address these concerns.

• Some statutory UK health agencies employ health

promoters to engage in community development work –

often in tandem with local authorities.

4. Empowerment Approach - Examples

• Social Inclusion Partnerships: - Great Northern Partnership (Aberdeen) – Moray Youth Partnership.

• Health Action Zones - England :Merseyside.

Dilemma!!!Local authority officials put forward a proposal that would see

school playing fields in Area A sold off for development to build a large factory unit. It is argued by the council officials that this development will boost the local economy, and the employment prospects of local people, many of who are unskilled and have been unemployed for some time.

However, local community activists and some health officials have been campaigning for some time to improve opportunities for people to become more physically active in the area and, the local community council (as elected local representatives) decide to object to the proposal on the grounds that the playing fields are recreational resource for their area.

What should happen?

5. Social Change Approach

• Targets groups and populations, top down method of working.

• Sometimes known as radical health promotion and is underlined by a belief that socio-economic circumstances determine health status.

• Its focus is at the policy or environmental level. • Aims is to bring about physical, social, economic,

legislative and environmental changes that will be health enhancing or promoting.

5. Social Change Approach

• Approach is based on the notion that to promote positive health it is necessary to tackle and diminish social and health inequalities.

• “Make the healthy choice the easier choice”.

• Healthy choices may be available, but this may require major structural changes.

Structural inequalities

• DoH Nutrition Task Force 1996 – survey showed that a healthy diet which includes fruit, vegetables, high fibre foods and less fat can cost up to a third more than a typical diet of a low income family.

Pause for thought

• If you were the nutrition and dietetic experts concerned with improving the nutritional quality of the nation’s diet - what would you do?

Health Promotion Principles revisited (1)

• Empowering - enabling individuals and communities to assume more power over the determinants of health.

• Participatory - involving all concerned at all stages of the process.

• Holistic - fostering physical, mental, social and spiritual health.

• Intersectoral - involving the collaboration of agencies from relevant sectors.

Health Promotion Principles revisited (2)

• Equitable - guided by a concern for equity and social justice.

• Sustainable - bringing about changes that individuals and communities can maintain once funding has ended.

• Multi-strategy - uses a variety of approaches – including policy development, organisational change, community development, legislation. (Rootman et al. 2001)

Final thoughts • Views and values held health and health

determinants influences health professionals’ and politicians’ decisions about which health promotion strategies or approaches should be used.

• Health promotion is characterised by the use of diverse approaches, and all have strengths and limitations.

• No single approach is or has been responsible for improvements in the health status of individuals and/or populations.

References

• Reference list to be handed out at the lecture.