Chapter 2. What is health promotion?
Chapter Contents
Defining health promotion17
Health gain, health improvement and health development18
Health education, health promotion and social marketing18
Multidisciplinary public health19
Involvement in public health20
The scope of health promotion20
A framework for health promotion activities24
Broad areas of competencies important to health promotion practice25
Occupational standards in health promotion26
Summary
This chapter starts with a discussion of the definitions of health promotion, and the related terms health gain, health improvement, health development, health education and social marketing. This is followed by an examination of the position of health promotion within the multidisciplinary public health movement. An outline of the scope of health promotion work is offered, with frameworks for activities for promoting health. Broad areas of practice covered by professional health promoters and the core competencies needed are set out with an outline of the framework for national occupational standards. Exercises are included to help you explore the range of health promotion activities and the extent of your own health promotion work.
Defining Health Promotion
Health promotion is about raising the health status of individuals and communities. Promotion in the health context means improving, advancing, supporting, encouraging and placing health higher on personal and public agendas.
Given that major socioeconomic determinants of health are often outside individual or even collective control, a fundamental aspect of health promotion is that it aims to empower people to have more control over aspects of their lives that affect their health.
These twin elements of improving health and having more control over it are fundamental to the aims and processes of health promotion. The World Health Organization (WHO) definition of health promotion as it appears in the Ottawa Charter has been widely adopted and neatly encompasses this: ‘Health promotion is the process of enabling people to increase control over, and to improve, their health’ (WHO 1986).
Health Gain, Health Improvement and Health Development
Health development, health improvement and health gain are terms that are also employed when discussing the process of working to improve people’s health. Health development is defined as the process of continuous, progressive improvement of health status of individuals and groups in a population (Nutbeam 1998). The Jakarta Declaration (WHO 1997) describes health promotion as an essential element of health development. Health improvement is frequently used by national health agencies. For example, there is a health improvement section on the Department of Health (DoH) website (http://www.dh.gov.uk) and NHS Scotland calls itself Scotland’s health improvement agency (http://www.healthscotland.com). A research study undertaken by Abbott (2002), however, found that people’s understanding of health improvement varied and ranged from explaining the term primarily as a government strategy – as a set of activities for the NHS – or in terms of the overarching purpose of health improvement. One definition sees health improvement as covering a wide range of activity, principally focused on improving the health and wellbeing of individuals and communities (so much like health promotion) (http://www.suffolkcoastal.gov.uk).
The term health gain emerged in policy documents in the late 1980s (for example, Welsh Health Planning Forum 1989). One useful early definition said health gain was a measurable improvement in health status, in an individual or population, attributable to earlier intervention (Nutbeam 1998).
Measurable means that it should be possible to put a value, usually a numerical value, onto health status, in order to demonstrate that a change has occurred.
Attributable means proving that the change in health status is the result of the intervention. This can be difficult. How will you be certain, for example, that a specific programme to reduce smoking has been effective when so many influences can affect smoking habits?
An intervention means a planned activity designed to improve health. It could be treatment, a care service or a health promotion activity.
The role of health promoters in assessing health needs, deciding on priorities, setting objectives and targets, allocating resources, and monitoring and reviewing outcomes can be seen as a health gain cycle (Fig. 2.1). Health gain is a useful concept. It focuses attention on health outcomes and on how different choices or priorities can be compared by considering the extent to which they contribute to health gains for individuals or groups.
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| Fig. 2.1 The health gain cycle. |
Health Education, Health Promotion and Social Marketing
The WHO (1998) defined health education as the consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health (see Smith et al 2006 for updates on the WHO glossary of health promotion terms). In the 1970s the range of activities undertaken in the pursuit of better health began to diverge from health education (Scriven 2005). There was also criticism that the health education approach was too narrow, focused too much on individual lifestyle and could become victim-blaming (see Ch. 1, Improving Health – Historical Overview) and increasingly work was being undertaken on wider issues such as political action to change public policies. Such activities went beyond the scope of traditional health education.
Health promotion as a term was used for the first time in the mid 1970s (Lalonde 1974) and quickly became an umbrella term for a wide range of strategies designed to tackle the wider determinants of health. There is no clear, widely adopted consensus of what is meant by health promotion (see Scriven 2005 for a detailed discussion of the development and use of the term). Some definitions focus on activities, others on values and principles. The WHO (1986) definition defines health promotion as a process but implies an aim (enabling people to increase control over, and improve, their health) with a clear philosophical basis of self-empowerment.
Recently in the UK, health-related social marketing has emerged as a prominent health promoting strategy to achieve and sustain behaviour goals on a range of social issues. There are a number of definitions of social marketing, but the description most generally in use is the systematic application of marketing, alongside other concepts and techniques, to achieve specific behavioural goals, for a social good and to improve health and reduce inequalities (French & Blair-Stevens 2005). The exact relationship between social marketing and health promotion is currently being debated, so there is no consensus on whether social marketing comes under the health promotion umbrella of approaches to health gain.
Multidisciplinary Public Health
In the last decade, national and local policy has focused on the development of multidisciplinary public health (see Berridge 2007 for a critique and overview of these developments). Public health work has been defined by Acheson (DoH 1998) as the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. The Faculty of Public Health (FPH) also uses this definition but offers guidelines specifying that public health:
• Is population based.
• Emphasises collective responsibility for health, its protection and disease prevention.
• Recognises the key role of the state, linked to a concern for the underlying socioeconomic and wider determinants of health, as well as disease.
• Emphasises partnerships with all those who contribute to the health of the population (http://www.fphm.org.uk).
Three spheres of public health have been outlined by Griffiths et al (2005):
Health improvement
• Inequalities
• Education
• Housing
• Employment
• Family/community
• Lifestyles
• Surveillance and monitoring of specific diseases and risk factors.
Improving services
• Clinical effectiveness
• Efficiency
• Service planning
• Audit and evaluation
• Clinical governance
• Equity.
Health protection
• Infectious diseases
• Chemicals and poisons
• Radiation
• Emergency response
• Environmental health hazards.
It is clear from these definitions and explanations that public health requires a wide range of competencies (Evans & Dowling 2002), that it is a multidisciplinary activity involving people from many professions and backgrounds (DoH 2001, Coen & Wills 2007) and that health promotion activities overlap with and are an integral part of the UK public health function (DoH 2005).
Involvement in Public Health
See also Chapter 1, section on national initiatives, for more about this report.
There are three levels of involvement in public health (DoH 2001):
1. Teachers, social workers, voluntary sector staff and health workers all have a role in health improvement. They need to adopt a public health mind set and appreciate how their work can make a difference to health and wellbeing, and where more specialist support can be obtained locally.
2. A smaller number of hands-on public health professionals, such as health visitors and environmental health officers, who spend a major part, or all, of their time in public health practice working with communities and groups.
3. A still smaller group of public health specialists from medical and other professional backgrounds, who work at a senior level with responsibility to manage strategic change and lead public health initiatives. This group includes health promotion specialists and medically qualified public health doctors.
The roles of professionals who contribute to health promotion work are discussed in Chapter 4.
The Scope of Health Promotion
The questions in Exercise 2.1 give examples of the wide range of activities that may be classified as health promotion. Answering ‘yes’ to each one indicates a broad view of what may be included: mass media advertising, campaigning on health issues, patient education, self-help, environmental safety measures, public policy issues, health education, preventive and curative medical procedures, codes of practice on health issues, health-enhancing facilities in local communities, workplace health policies and social education for young people. Answering ‘no’ indicates that you identify criteria that you believe exclude these activities from the realms of health promotion. For example, you may have said ‘no’ to Item 2 because increasing tobacco taxation would place a heavier burden on smokers in poor financial circumstances, thus putting their health even more at risk.
EXERCISE 2.1
Exploring the scope of health promotion
Consider each of the following activities and decide whether you think each is, or is not, health promotion:
| Yes | No | |
|---|---|---|
| 1.Using TV advertisements to encourage people to be more physically active. | □ | □ |
| 2.Campaigning for increased tax on tobacco. | □ | □ |
| 3.Explaining to patients how to carry out their doctor’s advice. | □ | □ |
| 4.Setting up a self-help group for people who have been sexually abused as children. | □ | □ |
| 5.Providing schools with a crossing patrol to help children across the road outside schools. | □ | □ |
| 6.Raising awareness of how poverty affects health. | □ | □ |
| 7.Giving people information about the way their bodies work. | □ | □ |
| 8.Immunising children against infectious diseases such as measles. | □ | □ |
| 9.Protesting about a breach in the voluntary code of practice for alcohol advertising. | □ | □ |
| 10.Running low-cost gentle exercise classes for older people at local leisure centres. | □ | □ |
| 11.Providing healthier menu choices at workplace canteens. | □ | □ |
| 12.Teaching a programme of personal and social education in a secondary school. | □ | □ |
| 13.Providing support to people with learning disabilities living in the community. | □ | □ |
| 14. Using social marketing tools to ensure behavioural change in a group of smokers. | □ | □ |
What were your reasons for saying ‘yes’ or ‘no’? Can you identify the criteria you are using for deciding whether an activity is ‘health promotion’?
Attempts to provide frameworks and models for classifying activities have helped to clarify the scope of health promotion (see Naidoo & Wills 2000 for an overview). Drawing on these, Fig. 2.2 identifies the activities that contribute to health gain and maps out all those activities which aim to improve people’s health. There are two sets of activities, those about providing services for people who are ill or who have disabilities, and positive health activities, which are about personal, social and environmental changes aiming to prevent ill health and develop healthier living conditions and lifestyles. These two sets of activities overlap, because they both contribute to health gain, and they are often closely related in practice. Ten categories of activities are identified, comprising two illness and disability services and eight types of positive health activities.
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| Fig. 2.2 Activities for health gain. |
Illness and Disability Services
Personal social services
This includes all those social services aimed at addressing the needs of sick people and people with disabilities or disadvantages whose health (in its widest sense) is improved by those services. This includes, for example, community care of mentally ill people and home help services for the elderly.
Healthcare services
This includes the major work of the health services: treatment, cure and care in primary care and hospital settings.
An important question when considering the boundaries of service provision by health promoters is: ‘If all illness and disability services improve health and produce varying amounts of health gain, are they all called health promotion?’ For example, is taking out someone’s appendix or placing a child in a foster home health promotion?
It is helpful to go back to the WHO (1986) definition of health promotion, about enabling people to increase control over and improve their health. Things that need to be done to people (like taking out their appendix or placing them in foster homes) are excluded from this definition, so are generally not considered to be health promotion activities (although they are health gain activities). But those aspects of care and treatment that are about enabling people to take control over their health and improve it (such as educating patients in the skills of self-care, or educating foster parents in the skills of parenting) are legitimate areas of health promotion. So is creating a health promoting environment by, for example, modifying a home to make it suitable for a person with disabilities or providing affordable housing for homeless people with health problems.
Positive Health Activities
Health education programmes
These are planned opportunities for people to learn about health, and to undertake voluntary changes in their behaviour. Such programmes may include providing information, exploring values and attitudes, making health decisions and acquiring skills to enable behaviour change to take place. They involve developing self-esteem and self-empowerment so that people are enabled to take action about their health. This can happen on a personal one-to-one level such as health visitor/client, teacher/pupil, or in a group such as a smoking cessation group or exercise class, or reach large population groups through the mass media, health fairs or exhibitions.
See Chapter 10, Chapter 11, Chapter 12, Chapter 13 and Chapter 14 for detailed information on carrying out these health promotion activities.
Health education programmes may also be a part of healthcare and personal social services, and because of this it is useful to understand the concepts of primary, secondary and tertiary health education.
Primary health education
This would reflect McKinley’s (1979) vision of upstream, preventative activity. It is directed at healthy people, and aims to prevent ill health arising. Most health education for children and young people falls into this category, dealing with such topics as sexual health, nutrition and social skills and personal relationships, and aiming to build up a positive sense of self-worth in children. Primary health education is concerned not merely with helping to prevent illness but with positive wellbeing.
Secondary health education
There is also often a major role for health education when people are ill. It may be possible to prevent ill health moving to a chronic or irreversible stage, and to restore people to their former state of health. This is known as secondary health education, educating patients about their condition and what to do about it. Restoring good health may involve the patient in changing behaviour (such as stopping smoking) or in complying with a therapeutic regime and, possibly, learning about self-care and self-help. Clearly, health education of the patient is of great importance if treatment and therapy are to be effective and illness is not to recur.
Tertiary health education
There are, of course, many patients whose ill health has not been, or could not be, prevented and who cannot be completely cured. There are also people with permanent disabilities. Tertiary health education is concerned with educating patients and their carers about how to make the most of the remaining potential for healthy living, and how to avoid unnecessary hardships, restrictions and complications. Rehabilitation programmes contain a considerable amount of tertiary health education with a focus on improving quality of life.
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