The process of attempting to promote health may include a whole range of interventions including:

Until the 1980s most of these interventions were referred to as ‘health education’ and the practice was almost exclusively located within preventive medicine or, to a lesser extent, education. In recent years, the term health promotion has become widely used. There is no agreed consensus on what health promotion is or what health promoters do when they try to promote health, nor what a successful outcome might be. Many professions, including nursing, have found health promotion to be part of an expanding job description. This development reflects the arguments presented in this book, that it is health and not illness or disease which should underpin health care work. Yet what practitioners do in the name of health promotion varies enormously. This chapter outlines the historical development of health promotion and considers different views on the purpose, the nature and the scope of health promotion practice.

The term health promotion is a recent one used for the first time in the mid-1970s (Lalonde 1974) and the Alma Ata conference (World Health Organization 1978) is cited as setting the agenda for health promotion. Its foundations are complex and differ between countries and regions but in general arose from:

The term health promotion is used in a number of different ways, often without any clarification of meaning. In 1985 when the term was becoming widely adopted, Tannahill (1985) described it as a meaningless concept because it was used so differently. Over a decade later, Seedhouse (1997) describes the field of health promotion as muddled, poorly articulated and devoid of a clear philosophy. These early understandings reflect the origins of health promotion and range from:

More recently, health promotion is defined by building on the Ottawa Charter (World Health Organization 1986) definition, as Nutbeam (1988, pp. 1–2) explains:

A shared understanding of the meaning and purpose of health promotion is elusive. A diversity of disciplinary and ideological perspectives and policy changes has resulted in apparently conflicting conceptualizations. Health promotion as a concept can thus be understood as:

The first phase of health promotion development is known as the ‘social hygiene period’ with roots in both public health and health education. Its origins of health promotion lie in the 19th century when epidemic disease eventually led to pressure for sanitary reform for the overcrowded industrial towns. Alongside the public health movement emerged the idea of educating the public for the good of its health. The Medical Officers of Health appointed to each town under the Public Health legislation of 1848 frequently disseminated everyday health advice on safeguards against ‘contagion’. Voluntary associations were also formed, including the London Statistical Society (1839), the Health of Towns Association (1842) and the Sanitary Institute (1876). The temperance movement held Band of Hope mass meetings, and through schools and churches lectured to young people on the virtue of abstinence. By the 1920s health education had become associated with diarrhoea, dirt, spitting and venereal disease! The evidence that between 10% and 20% of soldiers in the First World War had contracted venereal disease led to propaganda, one-off lectures and the first of ‘shock-horror’ techniques in which soldiers were shown lurid pictures of diseased genitals to dissuade them from having sex (Blythe 1986; Welshman 1997).

The second phase of health promotion development is known as the ‘personal services’ period. Changing patterns of morbidity and mortality shifted attention away from disease to personal behaviour. The Central Council for Health Education was established in 1927, paid for by local authority public health departments, and public health doctors formed the majority of its membership. An extract from some of the tasks listed as important reflects an emphasis on information, and education to bring about change in personal habits and behaviour:

The Central Council was principally concerned with propaganda and instruction. During the Second World War it delivered 3799 lectures on sex education and venereal disease which were attended by 340 000 people (Amos 1993). A database of health education film synopses is held by the British Film Institute (at http://www.ftvdb.bfi.org.uk/sift/organization/9345http://ftvdb.bfi.org.uk/sift/organization/9345) and confirms the emphasis on propaganda and instruction.

The Health Education Council (HEC), which was set up in 1968 as a quango – a quasi-autonomous non-governmental organization – reflected the Department of Health and Social Security’s, as it then was, medical model of health. The members were drawn from public health, and the medical and dental professions, with the inclusion of advertising and consumer affairs representatives. Its brief was to create a ‘climate of opinion generally favourable to health education, develop blanket programmes of education and selected priority subjects’ (Cohen Committee 1964). Similar health education agencies were set up in Wales, Scotland and Northern Ireland.

The HEC came to be associated with mass publicity campaigns such as Look After Yourself (LAY) which was launched in 1978. LAY reflected the view that people could be encouraged to adopt lifestyles which would lead to better health. The lead agency for health education in England consistently emphasized such mass campaigns and short-term initiatives. Sutherland, the first director of education and training at the HEC, has vividly described the pressures and lobbying which led the HEC away from confrontation with vested interests, such as agriculture or tobacco, and kept it confined to mass-media campaigns despite evidence of their limited effect (Sutherland 1987).

By the 1970s there was an increasing recognition that health policy could not continue to be confined to clinical and medical services, which were both proving expensive and not improving the health status of the population. Health education and the prevention of disease represented a means of cutting costs and an ideology which could place the onus of responsibility on the individual.

The message of the document is that improving health depends on individuals changing the way they live in order to avoid ‘lifestyle’ diseases. A decade later, in 1987, a similar message was put forward by the White Paper Promoting Better Health which suggested that the major killer diseases could be avoided if people took greater responsibility for their own health (Department of Health 1987). The Health of the Nation strategy was also permeated by a philosophy of individualism despite the acknowledgement in the strategy that ‘responsibilities for action are widely spread from individuals to government’ (Department of Health 1992). Later White Papers in England, Saving Lives: Our Healthier Nation (Department of Health 1999) and Choosing Health: Making Healthier Choices Easier (Department of Health 2004) similarly look to individuals to make informed decisions about their health. The latter document highlighted the following behavioural priorities:

Alongside this government response, however, was the awareness that poor health was linked to poverty. In 1980 the Black report, commissioned by the government, showed how those in lower social classes had a far higher risk of dying prematurely than more advantaged groups (Townsend & Davidson 1982). The HEC commissioned a further study on inequality, Inequalities in Health: The Black Report and the Health Divide (Townsend et al 1992). The report was published on a national holiday in August, ostensibly to avoid publicity, so damning was its evidence on the extent of poverty and deprivation. The last three decades have seen a re-emergence of public health measures and a recognition of the need to address the social, economic and environmental determinants of health. The Acheson report (HM Government 1998), commissioned by an incoming Labour government, recommended that as part of health impact assessment, all policies likely to have an impact on health should be formulated in such a way to favour the less well-off. In all countries, making the connection between the social determinants of health and health promotion policy and action is a major task, as discussed by the international Commission on the Social Determinants of Health (http://www.who.int/social_determinants/en/).Developing healthy public policy is the subject of Chapter 11. In many countries however, much of health promotion remains ‘downstream’, focusing on the behavioural determinants of ill health such as smoking rather than the material factors and sociostructural conditions outlined in Chapter 2.

In 1920, Winslow Professor of Public Health at Yale University described public health as:

In the UK health promotion and public health are terms that are often used interchangeably. Health promotion is sometimes distinguished as one of the processes in securing public health. In many countries there is understood to be a clear distinction: public health is the practice of public health medicine with an emphasis on the prevention and control of disease. This distinction is explored in greater detail in our companion volume, Public Health and Health Promotion: Developing Practice (Naidoo & Wills 2005).

Historically, public health has been driven by social policy as much as by medicine. The early public health movement in the 19th century in the UK used a medical scientific model to explain the disease process. The gathering of information and interpretation of quantitative data (epidemiology) was employed to underpin decisions. Social policy interventions were deployed to protect the public and prevent disease (see Chapter 11).

The UK Faculty of Public Health identifies three domains of public health practice: health improvement, service improvement and health protection. The term health promotion is not included. Instead, the term multidisciplinary public health has become widely adopted, signalling environmental, social and individual health dimensions. Our companion volume (Naidoo & Wills 2005) discusses the similarities and differences between public health and health promotion in more detail.

The World Health Organization and health promotion

The World Health Organization has played a key part in proposing a broader agenda for health promotion. In 1977 the World Health Assembly at Alma Ata committed all member countries to the principles of Health for All 2000 (HFA 2000: World Health Organization 1977) that there ‘should be the attainment by all the people of the world by the year 2000 of a level of health that will per-mit them to lead a socially and economically productive life’. The World Health Organization made explicit five key principles for health promotion in a discussion paper commonly referred to as the Copenhagen document:

1. It involves the population as a whole in the context of their everyday life, rather than focusing on people at risk for specific diseases.

2. It is directed towards action on the causes or determinants of health to ensure that the total environment which is beyond the control of individuals is conducive to health.

3. It combines diverse, but complementary, methods or approaches, including communication, education, legislation, fiscal measures, organizational change, community development and spontaneous local activities against health hazards.

4. It aims particularly at effective public participation supporting the principle of self-help movements and encouraging people to find their own ways of managing the health of their community.

5. Although health promotion is basically an activity in the health and social fields and not a medical service, health professionals – particularly in primary health care – have an important role in nurturing and enabling health promotion (World Health Organization 1984).

The context for the development of broad-based health strategies thus needed to be based on equity, community participation and intersectoral collaboration, The World Health Organization also identified that improvement in lifestyles, environmental conditions and health care will have little effect if certain fundamental conditions are not met. These include:

• Peace and freedom from the fear of war

• Equal opportunity for all and social justice

• Satisfaction of basic needs, including food and income, safe water and sanitation, housing, secure work and a satisfying role in society

• Political commitment and public support (World Health Organization 1985).

The World Health Organization launched a programme for health promotion in 1984, and conferences at Ottawa (1986), Adelaide (1988), Sundsvall (1991), Jakarta (1997), Mexico (2000) and Bangkok (2003) have further outlined areas for action. The practice and principles of health promotion developed in the Ottawa Charter (World Health Organization 1986) are still widely used to provide a framework for practice:

1. Building a healthy public policy

2. Creating supportive environments

3. Developing personal skills, including information and coping strategies

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