Chapter 4 Defining health promotion
Overview
The process of attempting to promote health may include a whole range of interventions including:
Foundations of health promotion
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:
Origins of health promotion in the UK
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 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 www.ftvdb.bfi.org.uk/sift/organization/9345http://ftvdb.bfi.org.uk/sift/organization/9345) and confirms the emphasis on propaganda and instruction.
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).
Health as an individual responsibility
To a large extent though, it is clear that the weight of responsibility for his own health lies on the shoulders of the individual himself. The smoking-related diseases, alcoholism and other drug dependencies, obesity and its consequences, and the sexually transmitted diseases are among the preventable problems of our time and, in relation to all of these, the individual must decide for himself (Department of Health and Social Security 1976).
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 (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.
Public health
In 1920, Winslow Professor of Public Health at Yale University described public health as:
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: