CHAPTER 1
Health Promotion and Public Health

Contents

1. What is health promotion?
2. Putting health promotion into practice - regrouping the five dimensions of the Ottawa Charter
3. Health promotion as a multi-disciplinary activity
4. The rationale for health promotion
5. Historical overview of health promotion
6. Criticisms of health education and the emergence of health promotion
7. Inequalities in health
8. The New Public Health
9. Debates in health promotion
10. The relevance of medical and social models of health and disease
11. Individual and structural approaches
12. Levels of health-promotion practice
13. Core values of health promotion
14. Coercion, persuasion or health-empowerment approaches
15. Ethics of health promotion
16. Principles of health-promotion practice
17. Health-promotion planning process
18. Needs/situation analysis
19. Defining the health-promotion strategy
20. Implementation/evaluation, reflection and learning
21. Some concluding remarks on health promotion
22. Further reading

Key issues within this chapter:

• Health promotion is a key element of public-health practice.
• Health promotion involves a combination of health education, service improvement and advocacy.
• Many health workers, professional groups, community-based workers and volunteers have a role in health promotion.
• Health promotion is an evolving discipline with many ongoing debates concerning principles and practice, including the balance between health education and legislation, the role of individualistic and structuralist approaches, the levels at which to operate, the nature of the core values/ethical principles, and the balance between coercive, persuasive and health-empowerment approaches.
• A systematic approach to planning health promotion needs to take into account assessment of needs and influences on health, and involves decisions on target groups, methods, settings and timing of activities.

By the end of this chapter you should be able to:

• understand the history of prevention, public health and the evolution of health promotion
• define health promotion and its component parts - health education, service improvement and advocacy
• have considered the debates in health promotion, including approaches and core values/ethical principles, and assessed your own personal approach
• apply principles of health promotion to planning a health-promotion intervention.

What is health promotion?

The starting point for any discussion of health promotion is the Ottawa Charter, which in 1986 set out the concept of health promotion (WHO, 1986). Alongside the five key areas of action, summarized in box 1.1, the Ottawa Charter also reaffirmed the importance of community participation and introduced the goal of empowerment - a concept of which we will say more later in this book.

Box 1.1 Extracts from the Ottawa Charter for Health Promotion

Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing 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 wellbeing.

HEALTH-PROMOTION ACTION MEANS:

Building Healthy Public Policy - Health promotion goes beyond health care. It puts health on the agenda of policy-makers in all sectors and at all levels. It directs policy-makers to be aware of the health consequences of their decisions and accept their responsibilities for health. Health-promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. It is coordinated action that leads to health, income and social policies that foster greater equity. Joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. Health-promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. The aim must be to make the healthier choice the easier choice.

Creating Supportive Environments - Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable. Systematic assessment of the health impact of a rapidly changing environment - particularly in areas of technology, work, energy production and urbanization - is essential and must be followed by action to ensure positive benefit to the health of the public. The protection of the natural and built environments and the conservation of natural resources must be addressed in any health-promotion strategy.

Strengthening Community Action - At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies. Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public participation and direction of health matters.

Developing Personal Skills - Health promotion supports personal and social development through providing information, education for health and enhancing life skills. By so doing, it increases the options available to people to exercise more control over their health and environment, and to make choices conducive to health. Enabling people to learn throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. This has to be facilitated in school, home, work and community settings. Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves.

Reorienting Health Services - The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health-service institutions and governments. They must work together towards a health-care system that contributes to the pursuit of health. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services, which refocuses on the total needs of the individual as a whole person.

Putting health promotion into practice - regrouping the five dimensions of the Ottawa Charter

Two of the action areas in the Ottawa Charter's concept of health promotion (box 1.1) - Developing personal skills and Strengthening community action - can be seen as different dimensions of health education. The action area Reorienting health services can be broadened to encompass other sectors such as schools, environmental services, community development and social services. Building healthy public policy and Creating supportive environments both involve advocacy. A practical approach to health promotion is to regroup the five components in the Ottawa Charter into the three areas of action: health education, service improvement and advocacy for policy changes (HESIAD) (see figure 1.1). In box 1.2 we show how the HESIAD framework can be applied to different health topics.

Figure 1.1 The HESIAD framework for health promotion

Advocacy Activities directed at changing policy of organizations or governments.

Health education Health education is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes.

Service improvement Promoting change in services to make them more effective, accessible or acceptable to the community.

Box 1.2 Examples of application of HESIAD

Activity 1.1

For one of the following, or a health topic of your own choice, apply the HESIAD approach and suggest contributions of health education, service improvement and advocacy: reduction of injuries among children from road traffic; promotion of measles immunization; prevention of falls in elderly people; reduction of sexually transmitted infections among young people; promotion of breast-cancer screening among Asian women.

Health promotion as a multi-disciplinary activity

Health promotion is a core part of the work of many different groups inside and outside health services - see box 1.3.

Box 1.3 Who does health promotion?

Health...