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MODELS OF MODELS OF HEALTH PROMOTIONHEALTH PROMOTION
Objectives: You students will
• Understand the parameters required for health promotion model
• Be able to apply those parameters on models they may suggest for your own society
MODEL OF HEALTH PROMOTION 1: FOUR MODEL OF HEALTH PROMOTION 1: FOUR PARADIGMS OF HEALTH PROMOTION (CAPLAN PARADIGMS OF HEALTH PROMOTION (CAPLAN AND HOLLAND - 1990)AND HOLLAND - 1990)
RADICAL HUMANIST
• Holistic view of health
• De-professionalization
• Self-help networks
HUMANIST
• Holistic view of health
• Aims to improve understanding and development of self
• Client-led
RADICAL STRUCTURLIST
• Health reflects structural inequalities
• Need to challenge inequity and radically transform society.
TRADITIONAL
• Health = absence of disease
• Aim is to change behaviour
• Expert-led
Radical change
Subjective
Social regulation
Objective
Nature of knowledge
Nature of society
MODEL OF HEALTH PROMOTION 2: HEALTH MODEL OF HEALTH PROMOTION 2: HEALTH PROMOTION METHODS USING BEATTIE’S PROMOTION METHODS USING BEATTIE’S TYPOLOGY (BEATTIE – 1991)TYPOLOGY (BEATTIE – 1991)
Advice
Education
Behaviour change
Mass media campaign
Counselling
Education
Group work
Legislation
Policy making and implementation
Health surveillance
Lobbying
Action research
Skills sharing and training
Group work
Community development
MODE OF INTERVENTION
Individual
Negotiated
Collective
Focus of intervention
Authoritarian
MODEL OF HEALTH PROMOTION 3: A TYPOLOGY MODEL OF HEALTH PROMOTION 3: A TYPOLOGY OF HEALTH PROMOTION (FRENCH – 1990)OF HEALTH PROMOTION (FRENCH – 1990)
DISEASE MANAGEMENT
• Curative services
• Management services
• Caring servicesDISEASE PREVENTION
• Preventive services
• Medical services
• Behaviour change
HEALTH EDUCATION
• Agenda setting
• Empowerment and support
• InformationPOLITICS OF HEALTH
• Social action
•Policy development
• Economic and fiscal policy
MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE MODEL OF HEALTH PROMOTION (DOWNIE et alet al – – 1990) 1990)
Health education
PreventionHealth protection
1
2
3
4
5
76
1. Preventive services, e.g. immunization, cervical screening, hypertension case finding, developmental surveillance, use of nicotine chewing gum to aid smoking cessation.
2. Preventive health education, e.g. smoking cessation advice and information.
3. Preventive health protection, e.g. fluoridation of water.
4. Health education for preventive health protection, e.g. lobbying for seat belt legislation.
5. Positive health education, e.g lifeskills with young people.
6. Positive health protection, e.g. workplace smoking policy.
7. Health education aimed at positive health protection, e.g. lobbying for a ban on tobacco advertising.
MODEL OF HEALTH PROMOTION 5: THE MODEL OF HEALTH PROMOTION 5: THE CONTRIBUTION OF EDUCATION TO HEALTH CONTRIBUTION OF EDUCATION TO HEALTH PROMOTION (TONES PROMOTION (TONES et alet al – – 1990)1990)
Healthy public policy
Lobbying
Advocacy
Mediation
Public pressure
Healthy social and physical environment
Healthy promoting organisation
Professional education
Healthy services
HEALTH
Healthy choices
Agenda setting
Education for health
Critical consciousness raising
Empowered participating community
APPROACHES TO HEALTH PROMOTION
Approaches in Health Promotion: the example of healthy eating
Approach Aims MethodsWorker/clientrelationship
Medical To identify those at risk from disease.
Primary health care consultation.
e.g. measurement of body mass.
Expert-led.
Passive, conforming client.
Approaches in Health Promotion: the example of healthy eating
Approach Aims MethodsWorker/clientrelationship
Behavior change
To encourage individuals to take responsibility for their own health and choose healthier lifestyles.
Persuasion through one-to-one advice, information, mass campaigns, e.g. ‘Look After Your Heart’ dietary messages.
Expert-led.
Dependent client.
Victim blaming ideology.
Approaches in Health Promotion: the example of healthy eating
Approach Aims MethodsWorker/clientrelationship
Educational To increase knowledge and skills about healthy lifestyles.
Information.
Exploration of attitudes through small group work.
Development of skills, e.g. women’s health group.
May be expert led.
May also involve client negotiation of issues for discussion.
Approaches in Health Promotion: the example of healthy eating
Approach Aims MethodsWorker/clientrelationship
Empowerment To work with client or communities to meet their perceived needs.
Advocacy
Negotiation
Networking
Facilitation e.g. food co-op, fat women’s group.
Health promoter is facilitator, client becomes empowered.
Approach Aims MethodsWorker/clientrelationship
Social change To address inequalities in health based on class, race, gender, geography.
Development of organizational policy, e.g. hospital catering policy
Public health legislation, e.g. food labelling.
Fiscal controls, e.g. subsidy to farmers to produce lean meat.
Entails social regulation and is top-down.
Approaches in Health Promotion: the example of healthy eating
Religion and Health - 3
Figure 1: Pathways of ‘Islamic Health Theory’
Quran & Ahadith
Five Pillars of Islam
Elements of Faith
Islamic Jurisprudence
Salutogenic Mechanism
Sense of coherence
Predisposing &Enabling factors
Behavior
Healthy Lifestyle
Putting Islamic Concepts Into Practice for Health Promotion 1
Act
Plan
Do
Check
• Precede-proceed model.
• Intervention mapping.
• A five-stage model.
Putting Islamic Concepts Into Practice for Health Promotion 2
Putting Islamic Concepts Into Practice for Health Promotion 2.1
The PRECEDE-PROCEED Model by Green & Kreuter, 1999
Visit the website below for a figure of this model.
http://oc.nci.nih.gov/services/Theory_at_glance/PP_Part_3_cont.html#anchor248267
Intervention mapping.
Putting Islamic Concepts Into Practice for Health Promotion 2.2
STEP 1: Proximal program objective matricesSTEP 2: Theory –based methods and practical strategiesSTEP 3: Program planSTEP 4: Adoption and implementation planSTEP 5: Evaluation plan
A five-stage model (Bracht et al. 1999)
Putting Islamic Concepts Into Practice for Health Promotion 2.3
COMMUNITY
ORGANIZATIONSTAGES
1. Community analysis
2. Design - initiation
3. Implementation
4. Maintenance - consolidation
5. Dissemination - reassessment
1. Community analysis.
Putting Islamic Concepts Into Practice for Health Promotion 3.1
An illustration using the five-stage model (Bracht et al. 1999)
2. Design - initiation.
Putting Islamic Concepts Into Practice for Health Promotion 3.2
An illustration using the five-stage model (Bracht et al. 1999)
3. Implementation.
Putting Islamic Concepts Into Practice for Health Promotion 3.3
An illustration using the five-stage model (Bracht et al. 1999)
4. Maintenance - consolidation.
Putting Islamic Concepts Into Practice for Health Promotion 3.4
An illustration using the five-stage model (Bracht et al. 1999)
5. Dissemination - reassessment.
Putting Islamic Concepts Into Practice for Health Promotion 3.5
An illustration using the five-stage model (Bracht et al. 1999)
Promoting Healthy Behavior
Behavior and Global Health
• Physical good health eludes billions of people• Death and disease from preventable causes
remain high
• Behavior is a key factor in determining health
“Health is a state of complete physical, psychological, and social well-being and not simply the absence of disease or infirmity.” (World Health Organization, 1948)
Ten Leading Risk Factorsfor Preventable Disease
• Maternal and child underweight
• Unsafe sex• High blood pressure• Tobacco• Alcohol• Unsafe water, poor
sanitation, & hygiene
• High cholesterol• Indoor smoke from
solid fuels• Iron deficiency• High body mass index
or overweight
Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002), accessed online at www.who.int, on Nov. 15, 2004.
Whose Behavior is Responsible For…
• Maternal and child underweight• Smoking and alcohol abuse • Unsafe sex • Unsafe water and lack of adequate sanitation
Maternal and Child Underweight
• Individuals (may resist nutrition education)
• Communities (male preference norms)
• Policymakers (fail to address poverty)
• Health planners and health workers (do not include nutrition programs for the poor)
Smoking and Alcohol Abuse
• Individuals (choice)
• Communities (norms regarding smoking)
• Health policymakers
• Legislators & tax assessors
• Tobacco company executives
• Decision-makers in marketing companies
Unsafe Sex
• Individuals (abstinence, fidelity, condoms)
• Communities (norms regarding male dominance
and multiple partners)
• Poverty (transactional sex for poor women)
• Health policymakers and health workers
(effective AIDS prevention programs)
Unsafe Water and Lack of Adequate Sanitation
• Individuals (where they fetch water, boiling
water, washing hands)
• Communities (fatalism regarding diarrheal
diseases, community latrines)
• Governments (ignore or underfund safe
water and sanitation needs)
Risky behaviors translate to diseases
Global Causes of Death
31%
9%
60%
Noncommunicable diseases
Communicable diseases,
maternal and perinatal
conditions, and nutritional
deficiencies
Injuries
Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).
Behavior change reduces risky behaviors
Health Promotion Means Changing Behavior at Multiple Levels
A Individual: knowledge, attitudes, beliefs, personality
B Interpersonal: family, friends, peers C Community: social networks, standards,
norms D Institutional: rules, policies, informal
structuresE Public Policy: local policies related to
healthy practicesSource: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at http://cancer.gov.
A: Individual-Oriented Models
• Individual most basic unit of health promotion
• Individual-level models components of broader-level theories and approaches
• Models– Stages of Change Model– Health Belief Model
Stages of Change Model
• Changing one’s behavior is a process, not an event
• Individuals at different levels of change
• Gear interventions to level of change
Source: James O. Prochaska et al., “In Search of How People Change: Application to Addictive Behaviors,” American Psychologist 47, no. 9 (1992): 1102-14.
Stages of Change Model (cont.)
Precontemplation
Action Decision
Maintenance Contemplation
Health Belief Model
• Perceived susceptibility and severity of ill health
• Perceived benefits and barriers to action
• Cues to action
• Self-efficacy
Source: Irwin M. Rosenstock et al., “Social Learning Theory and the Health Belief Model,” Health Education Quarterly 15, no. 2 (1988): 175-85.
B: Interpersonal Level:Social Learning Theory
• Interaction of individual factors, social environment, and experience
• Reciprocal dynamic
• Observational learning
• Capability of performing desired behavior
• Perception of self-efficacy
Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
Interpersonal Level:Social Learning Theory (cont.)
• Three strategies for increasing self-efficacy– Setting small, incremental goals– Behavioral contracting: specifying goals and
rewards– Self-monitoring: feedback can reinforce
determination to change (keep a diary)
• Positive reinforcement: encouragement helps
Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
C: Community-Level Models
• Analyze how social systems function
• Mobilize communities, organizations, and policymakers
• Use sound conceptual frameworks– Community Mobilization– Organizational Change– Diffusion of Innovations Theory
Community Mobilization
• Encompasses wider social and political contexts
• Community members assess health risks, take action
• Encourages empowerment, building on cultural strengths and involving disenfranchised groups
Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire, Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).
Organizational ChangeOrganizational Stage
TheoryDefine problem
Identify solutions
Initiate action
Allocate resources
Implement
Institutionalize
Organizational Development Theory
Worker behavior and motivation
Organizational structures
Diffusion of Innovations Theory
• How new ideas, products, and behaviors become norms
• All levels: individual, interpersonal, community, and organizational
• Success determined by: nature of innovation, communication channels, adoption time, social system
Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).
Diffusion of Innovations (cont.)
Nature of innovation
• Relative advantage over what is being replaced
• Compatible with values of intended users
• Easy to use
• Opportunity to try innovation
• Tangible benefits
Diffusion of Innovations (cont.)
Communication channels
• Mass media (enhanced by listening groups, call-in opportunities, and face-to-face approaches)
• Peers
• Respected leaders
Diffusion of Innovations (cont.)
Adoption time
• Awareness Intention Adoption Change
• Gradual
• Movement through groups– Pioneers– Early adopters– Masses
Diffusion of Innovations (cont.)
Social system:
• Identify influential networks to diffuse innovation: health systems, schools, religious and political groups, social clubs, unions, and informal associations
• Identify opinion leaders, peers, and targeted media channels to diffuse innovations
Health Promotion
Health Promotion Tools
• Mass media
• Social marketing
• Community mobilization
• Health education
• Client-provider interactions
• Policy communication
Source: Robert Hornik and Emile McAnany, “Mass Media and Fertility Change,” in Diffusion Processes and Fertility Transition: Selected Perspectives, ed. John Casterline (Washington, DC: National Academies Press, 2001): 208-39.
Behavior Change Successes
• Reducing malnutrition (micronutrient initiatives)
• Preventing malaria (insecticide-treated bednets)
• Helping children survive (breastfeeding)
• Improving maternal health (safe motherhood movement, emergency obstetric care)
• Making family planning a norm (worldwide efforts)
• Combating HIV/AIDS (Uganda program)
Combating HIV/AIDS in Uganda• Political support, multisectoral response• Decentralized behavior change campaigns• Focus on women and youth, stigma and
discrimination• Mobilization of religious leaders• Confidential voluntary counseling and
testing• Social marketing of condoms• Control and prevention of STIs
Source: Edward C. Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries (Westport, CT: Praeger Publishers, 2003).
Health Promotion: Lessons Learned
• Research underlying causes
• Address contextual factors
• Identify and reach key actors at every level
• Involve stakeholders throughout process
• Use sound behavioral theories
• Monitor and evaluate
Conclusion
• Improving global health requires behavior change at every level—individuals, families, communities, organizations, and policymaking bodies
• Evidence-based behavioral theories and successful behavior-change case histories point the way
• Next step: political will and sufficient resources
For More Information
Elaine M. Murphy, “Promoting Healthy Behavior,” Health Bulletin 2 (Washington, DC: Population Reference Bureau, 2005).
Available online at www.prb.org
Objectives: You Students will
• Understand the parameters required for health promotion model.
• Be able to apply those parameters on models they may suggest for their own society.