Chapter 5 Models and approaches to health promotion
Overview
The diversity in concepts of health, influences on health and ways of measuring health lead, not surprisingly, to a number of different approaches to health promotion. Chapter 4 began to explore the concepts of health education and health promotion. In this chapter, five different approaches will be discussed:
It is common for a practitioner to think that theory has no place in health promotion and that action is determined by work role and organizational objectives rather than values or ideology. We have argued elsewhere that practitioners should be aware of the values implicit in the approach they adopt: ‘Values thus determine the way in which the world is seen and the selection of activities and priorities and how strategies are implemented’ (Naidoo & Wills 2005, p. 13).
The medical approach
Aims
The medical approach to health promotion is popular because:
As we have seen in Chapter 1, the medical approach is conceptualized around the absence of disease. It does not seek to promote positive health and can be criticized for ignoring the social and environmental dimensions of health. In addition, the medical approach encourages dependence on medical knowledge and removes health decisions from lay people. Thus, health care workers are encouraged to persuade patients to cooperate and comply with treatment.
Public health medicine is the branch of medicine which specializes in prevention, and most day-to-day preventive work is carried out by the community health services which include specialist community public health nurses and district nurses.
Methods
For screening to be effective for the condition or disease:
The UK National Screening Committee oversees screening policies and gives advice based on available evidence. For more details visit www.nsc.nhs.uk/uk_nsc.
What methods can you think of that are used to increase the uptake of preventive screening services?
Mass media campaigns can raise awareness but an additional personalized trigger is often needed for people to access screening services. Personal invitations and appointments, telephone calls, telephone counselling and reminders from health care professionals have all been identified as helpful in increasing screening uptake. Removing economic barriers, such as transport or postage costs, can increase uptake in lower-income groups (Jepson et al 2000).
Evaluation
The medical approach is not always successful. Recently, whooping cough has re-emerged in countries with high vaccination coverage and low mortality rates (British Medical Journal 2002). What could account for this?
You probably included some of the following:
Behaviour change
Aims
This approach aims to encourage individuals to adopt healthy behaviours, which are seen as the key to improved health. Chapter 9 shows how making health-related decisions is a complex process and, unless a person is ready to take action, it is unlikely to be effective. As we saw in Chapter 4, seeking to influence or change health behaviour has long been part of health education.
Evidence supports some factors, e.g. lack of money (Morris et al 2000). Other factors, e.g. ‘food deserts’, are more speculative (Cummins & Macintyre 2002).
It is clear that there is a complex relationship between individual behaviour and social and environmental factors. Behaviour may be a response to the conditions in which people live and the causes of these conditions (e.g. unemployment, poverty) are outside individual control.
Methods
The behaviour change approach has been the bedrock of activity undertaken by the lead agencies for health promotion. Campaigns persuade people to desist from smoking, adopt a healthy diet and undertake regular exercise. This approach is targeted towards individuals, although mass means of communication may be used to reach them. It is most commonly an expert-led, top-down approach, which reinforces the divide between the expert, who knows how to improve health, and the general public who need education and advice. However, this is not inevitable. Interventions may be directed according to a client’s stated needs when these have been identified. For example, social marketing techniques (see Chapter 12) focus on finding out what consumers want and need, and then providing it.
The educational approach
Aims
The educational approach is based on a set of assumptions about the relationship between knowledge and behaviour: that by increasing knowledge, there will be a change in attitudes which may lead to changed behaviour. The goal of a client being able to make an informed choice may seem unambiguous and agreed upon. However this ignores not only the very real constraints that social and economic factors place on voluntary behaviour change, but also the complexities of health-related decision-making (see Chapter 9).
Methods
Psychological theories state that learning involves three aspects:
An educational approach to health promotion will provide information to help clients to make an informed choice about their health behaviour. This may be through the provision of leaflets and booklets, visual displays or one-to-one advice. It may also provide opportunities for clients to share and explore their attitudes to their own health. This may be through group discussion or one-to-one counselling. Educational programmes may also develop clients’ decision-making skills through role plays or activities designed to explore options. Clients may take on roles or practise responses in ‘real-life’ situations. For example, clients taking part in an alcohol programme may role-play situations where they are offered a drink. Educational programmes are usually led by a teacher or facilitator, although the issues for discussion may be decided by the clients. Educational interventions require the practitioner to understand the principles of adult learning and the factors which help or hinder learning (Ewles & Simnett 2003).