Chapter 5 Models and approaches to health promotion
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:
All of the approaches reflect different ways of working. Identifying the different approaches is primarily a descriptive process. The framework is descriptive – it does not indicate which approach is best, nor why a practitioner might adopt one approach rather than another. A number of theoretical frameworks or models of health promotion are outlined, discussed and assessed in relation to practice in the latter part of the chapter.
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).
Models of health promotion are not guides to action but attempts to delineate a contested field of activity and to show how different priorities and strategies reflect different underlying values. They are useful in helping practitioners think through:
The medical approach
This approach focuses on activity which aims to reduce morbidity and premature mortality. Activity is targeted towards whole populations or high-risk groups. This kind of health promotion seeks to increase medical interventions which will prevent ill health and premature death. This approach is frequently portrayed as having three levels of intervention:
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.
The principle of preventive services such as immunization and screening is that they are targeted to groups at risk from a particular condition. Whilst immunization requires a certain level of take-up for it to be effective, screening is offered to specific groups. For example, in the UK cervical screening every 3–5 years is offered to all women aged 25–64.
Preventive procedures need to be based on a sound rationale derived from epidemiological evidence. The medical approach also relies on having an infrastructure capable of delivering screening or an immunization programme. This includes trained personnel, equipment and laboratory facilities, information systems which determine who is eligible for the procedure and record uptake rates, and, in the case of immunization, a vaccine which is effective and safe. It can be seen then that the medical approach to health promotion can be a complex process, and may depend on the establishment of national programmes or guidelines.
In most districts, amniocentesis is only offered to women over the age of 35 and those with a family history of chromosomal abnormality. Yet 80% of children with Down’s syndrome are born to mothers under 35 simply because more women in this age group have babies. Amniocentesis is not a simple test. It carries a risk of miscarriage. It can also only be performed after 14–16 weeks of pregnancy when a possible termination is more difficult. It is less than 100% sensitive and therefore some women may go away falsely reassured. A termination and/or counselling is the only intervention available.
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 of preventive procedures is based ultimately on a reduction in disease rates and associated mortality. This is a long-term process and a more popular measure capable of short-term evaluation is, for example, the increase in the percentage of the target population being screened or immunized.
Although there appears to be a close correlation between immunization uptake and a decline in disease rates, the example of whooping cough suggests some caution is needed. In 1974 80% of children were vaccinated against whooping cough. Following media publicity about the safety of the vaccine, immunization rates fell and did not reach 80% population coverage again until 1987. There were major whooping cough epidemics in 1977–1979 and 1981–1983, suggesting that immunization had contributed to the decline in notifications. However, the overall decline in mortality from whooping cough was occurring before the vaccine was introduced in 1957, suggesting that better nutrition, living conditions and medical care may also be significant.
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?
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.
This approach is popular because it views health as a property of individuals. It is then possible to assume that people can make real improvements to their health by choosing to change their lifestyle. It also assumes that if people do not take responsible action to look after themselves then they are to blame for the consequences.
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.
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.
Many health care workers educate their clients about health through the provision of information and one-to-one counselling. Patient education about a condition or medication may seek to ensure compliance, in other words, a behaviour change, or it may be more client-directed and employ an educational approach.
Evaluating a health promotion intervention designed to change behaviour would appear to be a simple exercise. Has the health behaviour changed after the intervention? But there are two main problems: change may only become apparent over a long period, and it may be difficult to isolate any change as attributable to a health promotion intervention.
A recent systematic review of interventions using behaviour change methods to prevent weight gain found mixed results. Only one randomized controlled trial, that included various methods including a correspondence programme, goal setting, self-monitoring and being prepared for contingencies, reported significant positive results. The review concluded that progress in this field would be facilitated by:
The educational approach
The purpose of this approach is to provide knowledge and information, and to develop the necessary skills so that people can make an informed choice about their health behaviour. The educational approach should be distinguished from a behaviour change approach in that it does not set out to persuade or motivate change in a particular direction. However, education is intended to have an outcome. This will be the client’s voluntary choice and it may not be the one the health promoter would prefer.
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).
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).