Health Promotion: Principles,
Values and Definitions
Flora Douglas 2008
HE 3514 and HE4509
Department of Public Health
University of Aberdeen
Intended learning outcomes
Outline the basis for health
promotion as an area of public health
policy and practice.
Be aware of the main aims, values
and principles of health promotion
as described by the Ottawa Charter,
as a socio-ecological approach to
population health improvement.
Intended learning outcomes
Outline and critically discuss five
approaches to health promotion
identified from the literature
describing contemporary UK health
promotion policy and practice.
Why health promotion?
Health Promotion
What is it?
Health Promotion Origins
• Improving the health of •Focus of this health improvement
individuals, communities effort has shifted from
and populations is a long
standing societal issue. environments, systems and
populations to individual based
• First legislative action re approaches and back again.
health improvement went
beyond the individual and
sought to address the
socio-economic
conditions that people
found themselves in.
(1796)
20th Century focus on the
individual
• The focus on wider determinants of health, and
actions on environmental variables within public
health shifted towards more individualistic
approaches (focused on biology and behaviour)
round about the 1870s.
• During this time ideas about germ theory and
micro-causality took hold, and attention was
directed towards the role of immunisation and
vaccination in improving health (Ashton, J. 1988)
20th Century focus on the
individual (contd)
• Decline in infectious disease rates, and the
emergence diseases linked to unhealthy
‘lifestyles’ such as coronary heart disease and
cancer, also supported this change in public
health focus.
• Increasingly, chronic diseases were viewed as
being created in parted by the individual behavior
and life style choices, and subsequently efforts to
encourage individuals to make lifestyle changes
became a key focus of public health work.
The rise and fall of health
education?
• Health education - defined ‘as planned learning
experiences to facilitate voluntary change in behaviour to
develop consciously pursued health-directed behaviour’.
• Emerged as a discipline within public health movement
during the late 1800s, early 1900s - primary aim concerned
with encouraging behavioural change.
• The emergence of health education is often linked to the
rise of the temperance movement in the UK.
• Mass health education programme to deal with 1st World
War soldiers returning home with some form of venereal
disease (20%).
Limitations of health education
• However evidence indicated that health-related
behaviour and individuals’ are not just isolated acts,
always under the autonomous control of the
individual, but are socially conditioned, culturally
embedded and economically determined.
• Health behaviour and lifestyles regard it as a
combination of social and cultural circumstances that
shape and restrict behaviour, as well as the personal
decisions that one might make about in choosing one
behaviour over another.
Implications
• Attempts to change behaviour needed to take
account of cultural values, and, the economic
and environmental circumstances
surrounding and supporting the targeted
lifestyle change.
• This more holistic view of lifestyle justified a
more holistic approach to promoting the
health of individuals and communities,
(Tones, K. 200)
Emergence of New Public Health -
1970s
Key drivers
• A general, trans-national reappraisal of health care priorities
– rising health care costs
– an apparently limitless demand for healthcare
– a rapid growth in the elderly proportion.
• Emerging critiques of the role and effectiveness of medicine
versus social and environmental changes in population health
gain (McKeown 1976, llich, 1977)
• The emergence of feminist ideas about gaining more control over
health care decisions, and self-help groups in general.
• Concomitant rise in other similar movements such as community
development, communications and consumerism movements.
Contemporary Health
Promotion Origins
1. World Health Organisation (WHO) Declaration of Alma
Ata (Russia) 1978
– Improvements in health could not be determined
by investments in the health care systems alone –
prevailing view since the end of the 2nd WW.
– Needed to enrol other sectors in health
improvement efforts
2. Canadian Lalonde Report (1974)
3. Global Strategy for Health for All by the Year 2000
(WHO 1981)
4. Health Promotion: Concepts and Principles (WHO,
1984)
5. Ottawa Charter for Health Promotion (1986)
Definitions
“Health promotion is the process of
enabling people to increase control over
and to improve their health. …. Health is a
positive concept emphasising social and personal
resources, as well as physical capacities. Therefore,
health promotion is not just the responsibility of the
health sector, but goes beyond healthy lifestyles to
well-being.” Ottawa Charter for Health Promotion (1986)
Implications?
• Ottawa Charter health promotion = radical
social change.
• Enabling individuals to increase control over
the determinants of their health (or disease)
means challenging the status quo (accepted
ways of doing things – existing vested
interests) at an individual and collective level
(community/society).
• Health promotion happens within & out with
the health sector.
5 Health Promotion Actions
• Developing public •Creating supportive
policy. environments.
• Developing •Reorienting health
personal skills. services
• Strengthening
community action.
Pre-requisites for health
• Peace
• Shelter
• Education
• Food
• Income
• A stable eco-system
• Sustainable resources
• Social justice and equity
Health promotion’s founding
principles
• Concerned for the population as a whole,
in the context of everyday life, rather
than just focusing on those at risk from
specific disease.
• Is directed at the causes or determinants
of health to ensure that the total
environment, beyond the control of the
individual, is favorable to health.
Health promotion’s founding
principles
• Uses a combination of methods and approaches
communication, education, legislation, fiscal measures,
organisational change, community development and supportive
of emergent local developed health initiatives.
• Aimed at effective public participation by encouraging people to
find their own ways of managing health in their communities.
• An activity in the health and social fields and not a medical
service. Looks to health professionals in primary care as
having a role in nurturing and enabling health promotion.
World Health Organisation 1977
Health Promotion Policy
Update
• Bangkok Charter for “Health Promotion in
a Globalised World” World Health Organisation 2005 (6th Global health promotion
conference).
• Health promotion should be:
– Central to the global development agenda
– Core responsibility of all governments
– Key focus of communities and civil societies
– A requirement of good corporate practice.
5 approaches to health
promotion
1. Medical or preventive
2. Behaviour change
3. Educational
4. Empowerment
5. Social change
Naidoo and Wills (2000)
Main objectives of health
promotion
To prevent disease (Medical or Preventive)
To ensure people are well informed and able to
make “healthy” choices (Behaviour Change
and Educational)
To help people to acquire the skills and
confidence to take greater control over their
health (Education and Empowerment)
To change policies and environments in order
to facilitate healthy choices (Empowerment
and Social Change).
1. Medical or Preventive
Approach
• This approach is aimed at reducing
premature deaths (mortality) and
avoidable diseases (morbidity).
• Actions are targeted at whole populations
(eg. immunisation) or so called high risk
groups.
• Some argue this approach seeks to
increase the use of medical interventions
to promote health.
1. Medical or Preventive
Approach
Primary prevention – prevention of the onset of
disease through risk education. – smoking cessation,
cholesterol reduction.
Secondary prevention – preventing the
progression of disease – screening and other
methods of early diagnosis.
Tertiary prevention – reducing further disability or,
preventing the recurrence of illness, patient
education, palliative care.
1. Medical or Preventive
Approach: Characteristics
Is popular as it has high status, using
scientific methods – epidemiology.
In the short term, this approach is cheaper
than the treatment of people who have
become ill. (May not be the case in the
longer term as people live longer and
suffer from degenerative disease).
It is top down and expert led, medical and
health professionals and recognised as
having expert status.
2.Behaviour Change Approach
This approach aims to encourage
individuals to adopt “healthy”
behaviours that are regarded as key to
improving health.
This approach is popular - views health
as the property of the individual.
2. Behaviour Change Approach
Assumptions
People can make real improvements
to their health by changing their
lifestyle.
If people don’t take responsibility for
their actions they are to blame for the
consequences -victim blaming
approach.
2. Behaviour Change Approach
However, it has become
acknowledged that the But - the behaviour change
complex relationship exists approach remains popular
between individual
behaviour, social and with health promotion
environmental factors.
agencies!
Behaviour - it is now
recognised may be a
response to the conditions
people live in and the
causes of these conditions
may be outwith individual
control.
Media and behaviour change.
Pause for thought!!
One of strategies used to encourage
behaviour change (and popular with health
promotion agencies) is the use of multi
media campaigns.
Can you think of any mass media campaigns
that you have noticed that have been
concerned with encouraging behaviour
change?
3. Educational Approach
• Strongly linked to health education
• Seeks to provide knowledge and
information, and to develop the
necessary skills so that people can
make informed decisions about their
behaviour.
3. Educational Approach
Assumption
• Increasing knowledge may change in
attitudes, that may result in changed
behaviour.
• It is argued that this approach does
not necessarily set out to persuade
or motivate change in a specific
direction!
4. Empowerment Approach
• So-called bottom up approach - idea is premised on helping
people or communities to identify their own health
concerns, gain the skills and make changes to their lives
accordingly .
• This approach is considered by many to reflect most
faithfully the general principles of the Ottawa Charter
definition.
• Professional acts as a facilitator rather than expert – as a
catalyst for change – by supporting individuals and
communities to make or lobby for changes.
4. Empowerment Approach
• Approach described as a way of working which increases
people’s ability to change their social reality.
• Community development is a similar way of working, in that
CD professionals are concerned with the helping
communities to identify general/social concerns and work
with those communities to plan a programme of action to
address these concerns.
• Some statutory UK health agencies employ health
promoters to engage in community development work –
often in tandem with local authorities.
4. Empowerment Approach -
Examples
• Social Inclusion Partnerships: -
Great Northern Partnership
(Aberdeen) – Moray Youth
Partnership.
• Health Action Zones - England
:Merseyside.
Dilemma!!!
Local authority officials put forward a proposal that would see
school playing fields in Area A sold off for development to
build a large factory unit. It is argued by the council officials
that this development will boost the local economy, and the
employment prospects of local people, many of who are
unskilled and have been unemployed for some time.
However, local community activists and some health officials
have been campaigning for some time to improve
opportunities for people to become more physically active in
the area and, the local community council (as elected local
representatives) decide to object to the proposal on the
grounds that the playing fields are recreational resource for
their area.
What should happen?
5. Social Change Approach
• Targets groups and populations, top down
method of working.
• Sometimes known as radical health promotion
and is underlined by a belief that socio-economic
circumstances determine health status.
• Its focus is at the policy or environmental level.
• Aims is to bring about physical, social, economic,
legislative and environmental changes that will
be health enhancing or promoting.
5. Social Change Approach
• Approach is based on the notion that to
promote positive health it is necessary to
tackle and diminish social and health
inequalities.
• “Make the healthy choice the easier
choice”.
• Healthy choices may be available, but this
may require major structural changes.
Structural inequalities
• DoH Nutrition Task Force 1996 –
survey showed that a healthy diet
which includes fruit, vegetables, high
fibre foods and less fat can cost up
to a third more than a typical diet of a
low income family.
Pause for thought
• If you were the
nutrition and
dietetic experts
concerned with
improving the
nutritional quality
of the nation’s diet
- what would you
do?
Health Promotion Principles
revisited (1)
• Empowering - enabling individuals and
communities to assume more power over
the determinants of health.
• Participatory - involving all concerned at
all stages of the process.
• Holistic - fostering physical, mental,
social and spiritual health.
• Intersectoral - involving the collaboration
of agencies from relevant sectors.
Health Promotion Principles
revisited (2)
• Equitable - guided by a concern for equity
and social justice.
• Sustainable - bringing about changes that
individuals and communities can maintain
once funding has ended.
• Multi-strategy - uses a variety of
approaches – including policy
development, organisational change,
community development, legislation.
(Rootman et al. 2001)
Final thoughts
• Views and values held health and health
determinants influences health professionals’ and
politicians’ decisions about which health promotion
strategies or approaches should be used.
• Health promotion is characterised by the use of
diverse approaches, and all have strengths and
limitations.
• No single approach is or has been responsible for
improvements in the health status of individuals
and/or populations.
References
• Reference list to be handed out at
the lecture.
