Concept of Health Promotion

Concept of Health Promotion
Rakesh Singh
BPH, MPH, DGH
Nepal Bidhya Bhusan
Lecturer
School of Public Health
Patan Academy of Health Sciences
6/1/18 Concept of HP - Rakesh Singh

Nowadays we hear a lot about Health Promotion (HP)....
People refer to it in workshops and meetings....
Directors in DOHS use this term to describe nature of their work
and development workers discuss HP in relation to health
campaigns...
But what is HP?
What does it aim to do?
What ideas underpin HP?

TASK 1 - Identify common features of Health Promotion
projects/programmes
What examples of Health Promotion projects or campaigns
do you know of, either at a national level or in your local
district or region or state?
What do all these projects/programmes have in common?

National HP projects What they have in common
Open Defecation Free Campaign § They raise awareness and
promote skills to assist
people/groups to change
behaviour that is detrimental to
their health.
§ They develop supportive
environments in which healthier
choices are easier choices.
§ They … improve health
GBV: Zero Tolerance
Red Ribbon HIV/AIDS Awareness
Campaign
Child Abuse Helpline
Health promoting settings, e.g.
Health Promoting Schools
Health warnings on tobacco
advertisements

Feedback
• .....HP programmes are often not flagged or labelled as such.
• Instead, they are often found embedded within the broad
activities of health and developmentorganisations.
• They are also found in a variety of different settings, and
assume different approaches.
• HP activities are likely to be hidden within comprehensive
integrated health activities of inter-sectoral action.

Other common features of HP programmes
• Provide information about health enhancing initiatives, health
issues or a particular behaviour that has a negative effect on
health e.g. no smoking campaigns.
• Refer the public to other supportive structures or organisations
that provide additional support to the particular issue e.g. a
Childhelplinecounsellingservice.

Contd…
• Encourage the development of working partnerships across
different sectors e.g. between health and transport, housing,
engineering and planning.
• Contain health promoting messages that are targeted at
specific audiences and sometimes, developed in consultation
with the target audience.
• Contribute towards the development or implementation of
healthy publicpolicy.

Before exploring these Health Promotion
features further, let us look more closely at
what we mean by the concept Health
Promotion.

• Looking at any complex society, one can identify three
overlapping sectors of health care:
1. the popular sector i.e. the lay or non-professional
sector;
2. the folk sector i.e. the traditional or sacred sector
3. the professional sector i.e. the legally-sanctioned
sector such as western scientific medicine.
• Each sector contributes to how one might experience
and interpret what being healthy or sick means.

• For example, under popular sector, one might start
constructing one’s idea about health and illness from personal
experience.
q Experience of being sick, or taking care of family who is sickly.
q Listening to neighbourhood or community beliefs or advice
about how to keep away colds in winter or how important it is
to eat certain foods to combat a particular illness.

• Under folk sector, one construct ideas about health and illness
from a traditional healer, a diviner or a spiritualist.
q Health and illness is viewed by many in this sector as holistic
with all aspects of life being equally important.
q In other words, one’s relationship with others, the natural
environment, supernatural forces and any physical and/or
emotional symptoms would all be considered in a
consultationwith such a healer.

• Professional sector - western scientific medicine or allopathy,
includes medical practitioners. This sector holds a dominant
positionin our society.
• People’s ideas about health and illness will not be constructed
from any sector alone – nor will they necessarily seek relief
from illness from a single health practitioner or healer.
• A health worker need to move between the popular, the folk
and the professional sector.

Understanding the Perception
regarding these differences
?

DIFFERENT CONCEPTS OF HEALTH
• Difficult to define as everyone has a different concept of
health
• But it can be conceptualised or understoodmentally
• In other words, you can describe your concept of health but
not necessarily define it.
• The important thing is to think about your concept of health
and to be able to articulate and communicate it to others.

Contd…
• Equallyneed to respect other’s concepts of health.
• If to my neighbour or my colleague, being healthy means
being fit and never being ill, whereas to me health means to
have a sense of wholeness, well-being and peace – one should
acknowledge and respect this difference in opinion.

Contd..
• Many researchers and writers have explored different
definitionsor concepts of health.
• Discussed in terms of lay and health professional concepts or
definitionsof health.
• For example, a British Sociologist, Mildred Lillington Blaxter
(1990) working from a British sample of 9000 people, grouped
their lay definitions of health into a number of different
perspectives. It included:

Contd…
• Health as not ill or diseased i.e. the absence of disease.
• As individual behaviour e.g. if someone lives in a healthy way,
does exercise and or does not drink or smoke.
• Physical fitness e.g. being fit or strong, or lookinghealthy.
• Energy e.g. having energy and enthusiasm to do things.
• Social relationships e.g. health in terms of relationships with other
people.
• Function e.g. being able to carry out normal routines or having the
ability to do things.
• Psycho-social well being e.g. being in a state of good mental
health.

Contd..
• Consider how important it would be if you were developing a
national HP campaign (for example with the 9 000 individuals
that Blaxter included in her sample), to bear in mind just how
diverse people’sideas about health are.
• Also important to bear in mind the influence that the popular,
folk and professional sectors have on influencing your
audience’s interpretationof health.

• Discussing professional as opposed to lay perceptions of
health, it is notable that perceptions are influenced by
particular model of health or illness to which they subscribe.
• In HP literature there are often references to two opposing
views of health: the bio-medical model and social model of
health.

Medical and Social Models – two views of health
• Bio-medical- “the absence of disease” ....Assumption-disease is
generated by specific agents- changes in the body... Emphasises the
importance of alleviating symptoms or curing diseases.
• Define health “… more by what it is not than what it is”.
• This model halts its analysis at the actual disease – exploring other
determinants (apart from specific agent).
• Limited emphasis on preventionof disease.

Social Model
• Views health and ill health as being caused not by diseases alone
but by social conditions(poverty, gender, violence.....)
• Emphasises positive side of health...Defines-in terms of a state of
well-being.
• The link between the physical, psychological and social processes
also suggests that health is more holistic in nature, as is illustrated
by WHO Definition.

• Health Promotion: A Discussion Document on the Concept
and Principles, WHO – health as a human right and something
which requires prioritisation and social investment by all,
including governments, organisations, business and others.
• “The extent to which an individual or group is able,...to realise
aspirations (desire) and satisfy needs, and...to change or cope
with the environment. Health, therefore, is seen as a resource
for everyday life, not an object of living; it is a positive
concept emphasising social and personal resources, as well as
physical capacities” (WHO, 1984).

TASK 2 - Classify different perceptions of health
Responses to “What is needed in order to feel healthy and live a healthy life?.
Classifythese responses accordingto the two different models ofhealth.
Having money
No natural disasters (e.g. floods)
Having interesting, challenging work
Having a flushing toilet
Good roads
Feeling secure from danger or threat
Not to have diseases I can’t easily cope with
Not to have TB
Not smoking
Protected from discrimination
Having good friends
Having a job
Having a house
No violence
Feeling happy
Having enough food
Feeling well, happy, stimulated by life and
spiritually content
A clean environment
Feeling spiritually fulfilled
Being fit and lean
To feel strong and keen to take on new
challenges

a. Different ways of classifying these responses.
b. Being healthymeans different things to different people.Influenced by:
q The context in which they are living e.g. geographical or physical location,
housing,income,employment status.
q Current health status.
q Knowledge,experiences and beliefs about health.
As a health promoter, it is always important to reflect on what being healthy means
to you and what it means to your clients, .... important influence on the approach
to HP.
c. As a health promoter there will invariably be things that you cannot directly help
your clients with.
For example, ensuring that there is an accessible, well maintained and safe public
transport system falls outside of health service’s responsibility. However, a health
worker.....start lobbying...to put more traffic officers on duty around schools and
parks, or to run educational campaigns about road safety at primary
schools.....HW begin to work inter-sectorally to reduce the high rate of traffic
accidents or to increase road access to rural villages.
Professional skills or experience Broader developmental issues

BIO-MEDICAL MODEL OF HEALTH
INDIVIDUAL COMMUNITY
§Not to have diseases I
can’t easily cope with
§Not to have TB
§To quit smoking
§To be fit and lean
§To feel strong and keen to
take on new challenges
§Having money
§Having a job
§To be happy
§Protection from
discrimination
§Having good friends
§No violence
§Good roads
§A clean environment
§Having a house
§Feeling secure from danger
§Having a flushing toilet
§Having enough food
§No natural disaster (e.g. floods)
§Having interesting work
§Feeling spiritually fulfilled
§To feel well, happy and stimulated
in my life, and to be spiritually
content
SOCIAL MODEL OF HEALTH6/1/18 Concept of HP - Rakesh Singh

Dimensions of health
• When people speak about being healthy, they refer to a
number of different areas of their daily lives.
• These different areas have been conceptualised as different
dimensions of health.

PHYSICAL MENTAL
EMOTIONAL SOCIAL
SPIRITUAL SEXUAL
ENVIRONMENTAL
SOCIETAL
Dimensions of Health
Individual D
Broader/Societal D
Health
interrelated to
all aspects
“Holistic
Concept of H”

TASK 3 – Define (Health) Promotion
a) What does promote or promotion mean to you?
b) Given your concept of health, what does Health Promotion
mean to you?
c) In order to promote health what information do we first
need to understand?

Feedback
a) To promote means to advance, assist, encourage, lend support to,
market, publicise, help the progress of something, push for.
b) Health Promotion means to advance, to assist or to push for a
better healthier life for people.
To use an analogy: health and development workers often feel like
they spend all their time standing on the banks of fast flowing river
lifting people to safety. The health promoter works upstream and
tries to find out why people are falling into the river from the
beginning and how one can work together in preventing such
things from happening in the future.
c) In order to promote health effectively with individuals and
communities, first need to understand the causes or determinants
of ill-health.

Determinants of Health
• Two other factors which affect our way of seeing or
conceptualisingHP:
1. Determinants or causes of health and ill health
2. Inequity and explore how these factors impact on definition
and understandingof HP.

• Like your definition of health, what you view as the
determinants or causes of health also influences your
interpretationof HP.
• They affect the way you view the purpose of HP and the kinds
of interventionsthat you choose to make.

TASK 4 - Identify some of the determinants of health and ill-
health
Jot down categories of determinants or causes of health or ill-
health and rank them according to which ones you think are the
most important or have the most influence.

1. Genetic factors - determine individual’s predispositionto disease.
2. Biological factors - diseasecaused by bacteria or viruses.
3. Individual behavioural factors - contribute to disease, such as smoking,
drinking, lack of exercise.
4. Socio-culturalfactors,such as traditional,religious beliefs and practices.
5. Factors around work and living conditions, such as housing, sanitation,
transport, access to health services, income, adequate nutrition and
employmentopportunities.
6. Environmentalfactors,such as pollution, level of violence.
7. Broader political, economic and social factors, such as a country’s
constitution and laws, prevailing economic system, the available
resources and how these are distributed.
These factors affect the way in which a society is structured or
stratified, e.g. in terms of class, gender, race, age. They also impact
upon the other factors.
DETERMINANTS

Ranking of Determinants
• Influenced by your view of health and in turn influence where you, as a health
promoter,place your efforts.
• Depend on your judgement of the issues, but also the perspectives of those you
work with and the feasibilityofanyintervention.
• For example, if you were working with a group of youth and believed that
individual behavioural factors as the most important determinant to tackle, you
might focus on individual skills building session. These could include discussion
sessions on how youth could stop smoking or taking drugs or how they should
practise safer sex or encourage youth to take up some form of sport.
• However, if environmental factors such as the high levels of violence or factors
associated with poor living conditions were seen as priorities, you might focus
on advocating for the development of community safety programmes, or for
changes to be made in the design and layout of low-cost housing schemes, and
you might work with the local communities to become involved in lobbying for
stricter legislation regardinggender-based violence.

How the categories interact
• Political, economic and social factors - affects the other categories in various
ways.
• For instance, consider how the following government laws and policies could
determine and change economic and social conditions and how those changes
would impact on other levels of health:
q Providinghousingsubsidies for the poor.
q Expandinglocal health facilities to rural areas.
q Ensuring equal work opportunities for men, women and the physically
challenged.
q Restrictingthe levels of industrialpollution.
q Assertingthe propertyand inheritance rights of women .
q Supportingthe right of women to terminationofpregnancy.
q Banningsmokingin publicplaces and prosecutingdrunken drivers.

Contd…
• This intervention could improve the environment as well as the working
and living conditions. It could also challenge unhealthy cultural and social
practices, and reduce the negative effects of these factors, particularly on
the health status of disadvantaged or vulnerable groups.
• These broad determinants all have a major impact on the health of the
population.

TASK 4 – Classifying the determinants of HIV/AIDS
In the first column of the diagram below, jot down all the determinants that you can think of
in relation to women’s experience of HIV/AIDS.
Classify each of your determinants by ticking the category of determinants, into which it fits
(provided two examples of determinants to guide you).
Think of ways in which any of these categories of determinants are linked?
Categories of determinants
Determinants
Genetic &
biological
Individual
beliefs
Socio-
cultural
Work &
living
conditions
Environ-
mental
Political,
economic,s
ocial
Anatomically,
women are more at
risk of HIV infection
than men.
√
Some religions
forbid the use of
condoms, thereby
increasing the risk of
HIV transmission.
√
Include further
determinants here.
ê
Classifying the Determinants of HIV

• What we are trying to illustrate here is the complexity of
the situation and the fact that many different factors
contributeto this/any health problem.
• Addressing it as health promoters therefore requires you to
be aware of the complexity of the determinants and their
inter-connectedness.

Determinants Discussion of the interconnections between determinants
Genetic &
biological
factors
HIV, a virus, passes from one person to another through vaginal fluids and
semen, during sexual intercourse, through blood, during childbirth,
infected blood, through a needle stick injury or through IDUs.
Anatomically women at more risk, as larger exposed surface area of the
vagina and labia. In addition, mucosal surfaces in vagina are more
susceptible to be affected compared to hardened penile skin.
It is well documented that co-existing STDs increase the risk of HIV
transmission – 9 times greater where one partner is HIV+. Women are
particularly vulnerable in relation to this risk, as their symptoms are often
non-specific or asymptomatic or might not be perceived to be serious
enough to seek treatment. STDs in women thus often go undetected,
thereby increasing women’s risk of HIV and giving rise to infections.
INTER-CONNECTEDNESS OF, DETERMINANTS OF HIV/AIDS EPIDEMIC IN RELATION TO WOMEN’S
EXPERIENCE

Determina
nts
Discussion of the interconnections between determinants
Individual
behavioural
factors
Men and women who have many sexual partners and do not use condoms,
IDUs who share needles and syringes and HW who do not practise universal
precautions are placing themselves and others at risk of HIV transmission.
The use of alcohol and drugs... rational decisions about safer sex practices...
in relation to the HIV epidemic. For example, ... Decisions regarding using a
condom, having safer sex or in fact deciding not to have sex.
Alcohol level of violence, including sexual violence, which would then
place women in a position of risk.

Determinants Discussion of the interconnections between determinants (continued)
Socio-cultural
factors
The practice of dry sex places women at increased risk of HIV
infection due to vaginal tearing.
Religious beliefs that forbid the use of condoms might place
some women at risk of HIV infection.
Women are often blamed or stigmatised for having a STD and
thus might not seek early treatment for the infection.
Traditional beliefs and perceptions about masculinity, to
demand sex from his partner whenever he desires, or that
wearing a condom reduces a male’s sexual power, also place
women at risk of HIV.

Factors around
work and
living
conditions
In some communities, women do not have equal access to on-going
training and tend to be excluded from the formal economy. Where women
have been able to access skills and training, they have not always had the
power to negotiate equivalent work positions or conditions as their male
colleagues.
Having had less choice around what work they are able to do, women
have often had to explore other work options, such as sex work, or in
some cases, accepting gifts, favours or a place to stay, in return for sex. In
these situations, where women are economically dependant on their
clients/men, they are likely to be placed in a situation where they accept
money for sex without using a condom, or have to suffer abusive sexual
situations.
The level of sexual violence is increasing thereby increases their
vulnerability to HIV infection.
Environmental
factors
General degradation of environment, for example, lack of street lighting
creates an environment which is not safe for women to walk in.

Determinan
ts
Discussion of the interconnections between determinants (continued)
Gender In general, women have less power, not in a position to talk about and
negotiate safer sex practices. A woman is also more at risk of violence, abuse
or rejection by her partner if she asks him to use a condom .
Women have less power to negotiate equal salaries and employment
opportunities....more economically dependent on men. This has had grave
consequences for women when they have informed their partner that they
are HIV+, as often the partners have literally chased the women out of their
homes. Women have in many cases had to leave all their possessions and find
accommodation elsewhere, which in turn has increased their vulnerability to
further discrimination.
Lack of appropriate information places women in a less informed position,
where they are unable to anticipate or identify risky HIV practices.
Information about human rights and the rights of women has also not been
conveyed to young people.......domestic violence and customary marriage law
of.

Determinan
ts
Discussion of the interconnections between determinants (continued)
Broader
political,
economic,
and social
factors
Migrant labour system....men often had multiple sexual partners,
which placed their primary partner at risk of HIV infection when he
returned home. Women were left to work at home....suffer
considerable hardship and poverty. In case of husbands falling ill or
dying, women are left in an even more vulnerable position. ...to have
sex in exchange for food, shelter and support for their children.
People are not aware of laws which protect people in the workplace
and support anti-discriminatory HIV/AIDS. A lack of knowledge about
these laws is disadvantageous to women, particularly in the
workplace. For instance, a woman living with HIV/AIDS might face
discrimination in relation to how her colleagues treat her....affect
opportunities for promotion or to receiving benefits that she would
normally receive ..... potentially at risk of experiencing different
levels of discrimination in terms of their access to treatment, care
and support.

Conflict,
community
instability,
mass
migration,
breakdown
in family
relationships
Years of conflict .... instability within communities....disintegration
of support networks within the community, the separation of
families and increasing numbers of orphans and street children.
Increased poverty level and broken relationships place them at
risk of HIV infection.
Discriminatio
n on the
basis of
race/caste/et
hnicity
Women from low caste and ethnic groups have limited power,
access to skills development and the opportunity to make and act
on decisions that impact on their own lives, including their
health.

• Broader political, economic and social factors are linked to other
determinants and have an influence,either negativelyor positively.
• For example:
q Migrant labour system.
q The laws did not support the principle of equity or protect against
discrimination.
q Affected the working and livingconditions ofwomen.
• Women were (and still are) not afforded the same status as men and not
given equal access to formal employment and ongoing training
opportunities. Their earning power is thus reduced, and until recently, they
have not had adequate legal protection against gender discrimination in
the workplace,or gender violence at home or in the broader community.

• Further example illustrate the link between socio-cultural, gender factors and
biological factors.
In a situation where a woman is placed at risk of HIV transmission for
instance, when she is having sex with her partner, she might not have the
confidence, the skills, the economic self-sufficiency or even the choice to
insist that she is protected from the risk of HIV transmission. Coupled with
her biological susceptibility, a woman is thus placed in a significantly more
vulnerable position.
• Another example is the situation of HIV+ woman who has to make complex
decisions about motherhood.
For instance, if she decides to have a child, she risks transmitting HIV to her
child and then has to live with the consequences of this decision if her child is
HIV+. If she decides not to have a child, she might face rejection and even
potential abuse from her partner and her family. Mother-to-child
transmission also inadvertently carries with it a stigma, as women are seen as
the carriers of the disease. This reinforces a commonly held belief that
women are in fact to blame for the epidemic.

• Ultimately all these determinants have a role to play in determining the
level or health status ofthe individualor community.
• Because of the relationship between all these factors, people working in
the area of Health Promotion need to consider all of the determinants
when developing and implementing an intervention in relation to women
and HIV/AIDS (any health problem), whether targeted at the general
public,at men, at the youth or at women.

LEVELS OF DETERMINANTS
• National or global levels:
Related to broader economic, political and social causes, such as the system,
laws and regulations.
• Environmental levels:
Related to the living and working environments, and the natural environment.
• Community levels:
Related to community practices, attitudes and norms.
• Individual levels:
That are close to or part of an individual, like those relating to genetic,
biological and physical causes and individual behaviour.

• In HP, recognising how determinants are inter-linked, try to tap into and
work with the different levels.
• For example, with HIV, try to encourage young women to delay practising
sex, or to ensure that they seek immediate treatment for STDs. This is an
intervention that taps into the most individual or local level of
determinants.
• However, working with only one level of determinants could be detrimental
to our health development workin the longterm.
• For example, whilst we may be ensuring that women receive early
treatment for their STDs, we have not adequately dealt with the fact that
women also need to be provided with the skills to prevent STD infection.
For instance, they need easy access to condoms and to be able to
communicate effectivelywith their partners.

• As health promoters, different levels of determinants need to
be looked upon so that development of realistic health
promotion interventions can be done. Take for example the
issue of the large numbers of children with scalds and burns.
• As a health promoter working in such an institution, one
would begin to think about what role the team could play or
what would be an appropriate intervention to assist in
reducing such accidents.

Perhaps asking the question “Why?” could begin such a brainstorm
session:
• Why are we seeing so many children with burns and scalds?
• Is it because families are living in crowded, informal houses without
adequate cooking and cleaning facilities?
• Is it because adults are unaware of the care and precautions that need to
be taken when using paraffin, gas or hot water near children?
• Is it because children are being left at home unsupervised – without
adequate adult supervision?
• Is it because the accident prevention campaigns have been inadequate?
• Is it because parents have no choice but to leave their children at home
as they need to go out and work and are unable to afford regular
childcare?

• By asking the question “why?”, focus on the cause upstream and then begin
to consider how one might plan an intervention that focuses on both those
determinants that are close to the individual (like educating parents and
care-givers about safety in the home) and broader determinants like housing
regulations,access to electricity and water and economicopportunities.
• In planning an intervention, the HP team might consider setting up a joint
project with the concerned stakeholders to host an awareness raising
workshop.
• Also consider advocating small business initiative to establish child care so
that working parents can leave their children in safety.
• The team might also consider working with local businesses that are selling
gas, paraffin and cooking utensils to support a child safety campaign. For
example, they could ask shop owners to display posters about safety and to
stock and sell paraffin safety caps - a campaign which could be supported by
a local community-based radiostation.

Health Promotion intervention Level of
determinant
Advocate that workplaces offer adequate opportunities for workers to be supported in taking their TB
treatment.
Establish a community-based condom distribution and education programme.
Encourage TB patients to join a directly observed treatment shortcourse (DOTS) programme.
Encourage family and household members ofTB patients to come to the clinics for screening.
Advocate for the introduction oflegislation which ensures thatpeople living with HIV/AIDS are not
discriminated againstin the workplace or within the health services.
Encourage young adolescentwomen to delay practising sex.
Produce preventive HIV educational materials and facilitate lifeskills sessions for youth.
Educate children abouthow to clean their teeth regularly and correctly.
Implementan inter-sectoral programme thatencourages other developmentprojects and
organisations to work in collaboration with the health services in informing their clients abouthow to
preventTB, the signs and symptoms of TB and how to access treatment.
Advocate for an optimal level of fluoride to be maintained in the local water supply.
Ensure that men and women seek immediate treatment for STDs.
Advocate for improved quality in housing construction,so as to reduce overcrowding and improve
ventilation.
Run educational workshops on gender and violence for local councillors.
Encourage parents to adopthealthy eating routines for their children e.g.less sugar and less
frequently.
TASK 6 – Identify levels of HP interventions
Listed below are some HP interventions that have commonly been used in relation to the three health issues HIV/AIDS, TB
and tooth decay. Identify which level of determinants each intervention tries to address.

Determinants close to the individual
• Encourage youngadolescent women to delaypractisingsex.
• Ensure that men and women seek immediate treatment for STDs.
• Encourage TB patients to join a directly observed treatment shortcourse
(DOTS) programme.
• Encourage family and household members of TB patients to come to the
clinics for screening.
• Educate children about howto clean their teeth regularlyand correctly.
• Encourage parents to adopt healthy eating routines for their children i.e.
less sugar and less frequently.
• Produce preventive HIV educational materials and facilitate lifeskills
sessions for youth.
• Establish a community-based condom distribution and education
programme.

Determinants that relate to living and working
conditions and the natural environment
• Implement an inter-sectoral programme that encourages other
development projects and organisations to work in collaboration with the
health services in informing their clients about how to prevent TB, the
signs and symptoms ofTB and howto access treatment.
• Advocate that workplaces offer adequate opportunities for workers to be
supported in takingtheir TB treatment.

Determinants that relate to broader economic, political
and social causes, such as systems, laws and regulations
• Advocate for the introduction of legislation which ensures that people
living with HIV/AIDS are not discriminated against in the workplace or
within the health services.
• Advocate for an optimal level of fluoride to be maintained in the local
water supply.
• Advocate for improved quality in housing construction, so as to reduce
overcrowdingand improve ventilation.

• A single HP intervention, whilst it might be aimed at a particular set of
causes or level of determinants, might also have an impact on the other
levels of determinants.
• For example, running an educational workshop on gender and violence for
local councillors (activist/leaders) in a community is a HP intervention
aimed at increasing awareness about the issue....thus aimed at
determinants close to individual. However, it might also encourage the
participants to reflect on how safe their communityis for women.

• They might then lobby for changes in their environment and in local
government regulations, which try to reduce the current level of gender
violence.Such intervention might include:
q Advocatinglife-skills programmesbe run in all schools.
q Installingmore street lights in each neighbourhood.
q Training the local health workers and police force on gender issues and
gender violence.
q Increasing the allocation of resources to the police service in order that
more communitypolice officers can be employed at local police stations.
q Introducing new regulations on the handling of domestic violence by the
police.
Individual
L & W EnvBroader

• Dividing determinants into categories is a useful analytical tool that helps
to recognise the importance of addressing the different levels of causes of
ill health.
• It is important in the process of planninga HP intervention to consider:
q firstly, how the different levels of determinants interact with one another
in causingill health or a disease,and
q secondly, how HP interventions aimed at different levels of determinants
could work alongside and complement one another.
• Generally, an intervention aimed at only one level of determinant will have
less chance of success than a Health Promotion intervention that
recognises the different levels of determinants.

INEQUITY AND HEALTH PROMOTION
• Talking about health determinants,inevitablyraises the issue ofinequity.
• Individuals, communities and countries with the least resources unfairly
carry the burden of ill-health and mortality.
• The link between poverty and ill health is apparent where differences exist
between the different sectors of our society.
• The distribution of inequity generally reflects or falls along the lines of
race, class, gender and age.

• When working in the field of HP, it is important to clarify what you and
others understand health to mean, and what the causes or determinants
of ill-health are.
• It affects the way you and others view the purpose of HP, the ideals and
values upon which HP activities are based and the choices made in
developingHP interventions.
• People’s definitions ofHP embodythese ideas.

TASK 7 - Summarise the factors which affect your understanding of HP
Take some minutes to make a mindmap of your understanding thus far of the
factors which affect your understandingofHealth Promotion e.g. inequity.
So far we have looked at definitions, perceptions and determinants of health,
including the issue of inequity. These ideas helped us to clarify what we mean
by health. They are also crucial to understanding what we mean by Health
Promotion.

TASK 8 - Analyse definitions of Health Promotion
Read the six definitions of HP below. What concept and model of health and what determinants of health is
each one likely to be based on?
1. “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 well-being, 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 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 life-styles to well-being” (Ottawa Charter for Health Promotion, 1986).
2. “Health promotion is health education and related organisational, political and economic interventions that are
designed to facilitate behavioural and environmental changes to improve health” (Green in Wass, A. 1994: 39).
3. “The terms health promotion and health education are not interchangeable. Health promotion covers all aspects of
those activities that seek to improve the health status of individuals and communities. It therefore includes both health
education and all attempts to produce environmental and legislative change conducive to good health. Put another
way, health promotion is concerned with making healthier choices easier choices” (Dennis et al, in Naidoo & Wills,
1994: 77).
4. “Health Promotion work has to recognise the prevailing social, economic, political and cultural context in which we all
live. In recognising the powerful links between personal and political issues, we assert the need to challenge
inequalities and oppression wherever they may arise. Health promotion work seeks to oppose inequity and oppression
based on race, ethnicity, age, gender, disability, class, sexual orientation and religious belief. The task of health
promotion is to enable, facilitate and empower individuals, groups and communities in order that they gain and
maintain control of their lives and their health. Education and training for health promoters must be compatible with
these aims” (Dr Rachael Dixey, Leeds Metropolitan University, UK).
5. “Health promotion is the art and science of helping people change their lifestyle to move towards a state of optimal
health” (O’Donnell ,M. in Reddy & Tobias, 1994: 23).
6. “Health promotion is a set of activities that aim to promote healthy living and to prevent disease through information,
skills building and the provision of health care” (South African health and development worker).

• Definitions (1) to (4) emphasise the Social Model of health. They support the
idea that health is a positive, holistic concept and that the health of individuals
and communities is affected by a range of determinants (social, political,
economicand cultural).
• Whilst it is generally accepted that the Ottawa Charter is strongly based within
a Social Model of Health framework, some people have interpreted the first
line of the Charter as being conservative. In other words they believe that
whilst one might be able to increase the level of control one has over one’s
health, that does not necessarily mean that one is assured of being able to live
in a good social environment.
• Definitions (5) and (6) are somewhat narrower and seem to imply a focus on
promoting the health of individuals. They emphasise biological and individual
behavioural determinants.

Some of the common themes which underpin the first three definitions are:
• HP is a process - it does not happen overnight, but is rather a longer-term set
of sustained activities and interventions.
• HP aims to improve the health status of individuals and communities and
enable them to gain increased control over their health.
• Based on the philosophyofself-empowerment.
• Entails different strategies, such as providing information and building skills, to
developingpolicyand legislation.
• HP is not equivalentto health education,but encompasses it.
• Involves inter-sectoral action and workingin partnershipwith other sectors.

• The last two definitions of HP are considerably more individualistic in their
emphasis and would most likely be focused on working towards attitude
and behaviour change within a health care setting.
• They assume that individuals have considerable influence over their
environment, and that a healthy outcome would automatically result from
the changes made in behaviour.

• One of the challenges that a health promoter may be faced with is
working in an environment where different parties hold different
understandings ofHP.
• Our conceptualisations affect our responses to health problems and
strategies for HP; health promoters need to develop a way of dealing with
these differences.
The next task offers you an opportunity to prepare yourself for this
problem.

TASK 9 – Managing different understandings of Health Promotion
Imagine that you are going to set up a HP project involving health colleagues,
other professionals (such as teachers and engineers) and community members.
It is likely that everyone does not share the same understanding of health and
of the role that determinants play in influencing health or ill health. People are
also likely to have had different experiences, and thus have different levels of
familiaritywith the concept of HP.
a) How would this affect the project?
b) How would you cope with this situation?
c) What would you do at the start of the project?

Feedback
• Universally, it is unlikely that a single concept of health, which is
acceptable to all, will ever be developed.
• Instead,diverse and competingdefinitions are inevitable.
• This can lead to confusion, misunderstanding and lack of true co-operation
when settingup a HP project.
• Ultimatelythis can undermine the success of the project.
• To address these problems and to work successfully with colleagues and
the community, it is important for everyone involved to share their
understandingofhealth and HP.

Contd..
• You could suggest that this be done as part of an ice-breaker or introductory
exercise in your first meeting or workshop.
• You could then reach consensus on the main elements of these definitions
through group discussion.
• This awareness-raising exercise could be the first step towards establishing a
good working relationship and forging a closer understanding of what HP
means for your team members.
• It might also allow the group to start thinking about the appropriate level of
determinants to target the HP intervention.

AIM GOAL
Health Promotion
A process of
enabling people to
increase control
over the
determinants of
Health and thereby
improve health
It embraces actions
•Directed at strengthening
the skills & capacities of
individuals so that they can
change and cope with the
environment.
•Directed towards changing
social, environmental &
economic conditions to
alleviate their negative impact
on public or collective health
and individual health.
PRINCIPLES
& METHODS
•Participation is essential to sustain health promotion
•Health Promotion action is not the responsibility of the health sector alone-it
involves all sectors, systems and structures that govern our social, economic and
physical environment.
6/1/18
Concept of HP - Rakesh Singh

TASK 10 – Reflect on your initial definitionof Health Promotion
Look back at your definition of health promotion in Task 2. Are you still
comfortable with this definition? If you are, that’s fine! However, if
you feel that you have a different understanding of Health Promotion
now, try rewriting your original definition to fit with your new
thinking.

• By now, you probably have a fairly strong sense of how our values,
experiences and our own critical perspectives influence the way we
conceptualise Health Promotion,and therefore the strategies we use.
• In order to develop our understanding even further, we need to look at
the history of the Health Promotion Movement to find out where Health
Promotion originated.

Forerunners of Health Promotion

AN OVERVIEW OF THE HISTORY OF
HEALTH PROMOTION
TASK 11 – Clarify some terms
Historical accounts often describe particular events, gatherings
of people, documents, laws etc as landmarks, milestones and
watersheds. What do each of these three terms mean, in their
original usage or literally and in everyday usage?

• A landmark literally means an object that is easily seen in a landscape. In
everydayuse it means an important historicalevent.
• A milestone literally referred to a stone that used to be placed beside the
road to mark the distance between towns. In everyday use it also means
an importantevent in life or history.
• A watershed literally describes a line of high land from which streams flow
down on all sides. In everyday use it means a turning point in the course of
events.

TASK 12 – Think about the history and forerunners of Health Promotion
a)What do you know about the history of Health Promotion? Where, when,
how and why did it start? What were the landmark or watershed dates,
events and documents associated with it? Jot down any knowledge you
have in a mind map like the one below.
b)The origins of the term Health Promotion is linked to activities that took
place around the 19th centuryin Europe.Whyis this?
c)Can you think of any examples of health promoting activities which took
place earlier in history,and in places other than Europe?
History of Health
Promotion

a) Your mind map will be helpful in reminding you that you already have some
prior knowledge about the topic
b) 1. The term Health Promotion is associated with 19th century Europe
because this was the first time in more recent history when public health
concerns were officiallyrecognised and seen to be of national importance.
2. It is interesting to note that many of the popular Health Promotion texts
start discussing the history of Health Promotion from this period (i.e. the
19th century) onwards and focus exclusively on public health legislation and
reform that was implemented in Europe,Britain or North America.

Contd…
3. Very few writers begin discussing the history of Health Promotion by
using examples of Health Promotion interventions from earlier centuries or
describing traditional indigenous practices or beliefs about health and
disease.
4. It is an interesting bias and reflects the focus of the authors on
documenting events in their own countries for the interest of their first
world readers.
5. It is also perhaps a reflection on the lack of documentation about
indigenous health practices which were considered by many in the colonial
era to be unscientific.
6. This was partly because practices were transferred from one generation
to the next through oral tradition and oral communication rather than the
written word.

Contd…
c) However, histories of Public Health show that some form of collective public
health measures have always been implemented by societies. Strategies to
promote health would have inevitably formed a part of these measures,
although these would not have been called HP.
Examples include:
-The Roman publicbaths.
-Roman laws governing burial of the dead and regulating dangerous animals
and unsound goods.
-The regulation ofprostitution in Ancient Rome and Greece.
-Inoculation against smallpoxin India and China before the Christianera.
-The isolation of people with leprosy in Europe in the Middle Ages (5-15th
Century.
-The quarantiningofships by the Venetians (Italy).

• Western concept of public health and concepts of health and disease
would have had little relevance or significance to the indigenous people
as hunter gatherers they did not have the Public Health problems
associated with permanent settlements.
• Traditional healers use of natural products for healing was part of the
indigenous practice which had little connection to European concepts of
Public Health.
• The world including developing nations have a rich history of indigenous
healing. To what extent has this indigenous practice been incorporated
into the recordingof our local Health Promotion history?

Health Promotion Era
Milestones in the development of health promotion

The Health Promotion Movement
The four key movements or eras affecting HP:
1. Early Public Health Movement i.e. the concern with environmental
conditions.
2. Medical Era i.e. the belief that medicine had all the answers.
3. Health Education Era i.e. that medicine does not have all the answers.
4. New Public Health Movement/Health Promotion Era i.e. that Health
Education does not solve everything and can result in blaming the
victim.

DIFFERENTIATING HEALTH EDUCATION
AND HEALTH PROMOTION
• Since the mid-1980’s, there has been considerable debate
about the difference between Health Promotion and Health
Education.

TASK 12 – List the differences between Health Education and
Health Promotion
Jot down the main differences between Health Education and Health
Promotion in terms of their
•Aims.
•Activities and strategies.

• Both have the same aim, “to improve or protect health”. However, the
scope of their activity varies.
• In the case of HE, most activity centres on providing learning opportunities
for individuals and communities so that they are able to voluntarily
change their behaviour.
• They acquire information and skills to help them initiate a change that
enhances their well-beingand their health.
• HP activity is much broader and includes both HE
And:
1. The provisionofpreventative healthservices.
2. Measures to protect the physical environment and make it conducive to
health
3. The mobilisationofcommunityresources.
4. The implementationoforganisational policies which promote health.
5. Economicand regulatoryactivities.

HP Vs HE
• The two concepts,HE and HP are symbioticstrategies.
• A key feature that distinguishes HP from HP is that HP involves environmental
and political action.
• Similarly, Tones and Tilford (2001) have suggested that it is possible to distil
the concept of HP into an essential formula:
Health Promotion = Health Education x HealthyPublicPolicy
• HP is the product of both HE and HPP.
• The multiplication sign x literally means to add a given amount several times
over.
• Here the given amount is HE which is added as manytimes over as HPP.
• In other words, when HE and HPP are multiplied, they produce a far greater
effect than just the sum of the two. HE and HPP - if implemented together
produce an effect that is far greater than the individual parts.
• This formula serves to illustrate how central both Health Education and policy
are to the achievement of individual, community and national health status,
and how symbiotic or inter-connected the relationship is between Health
Education and the broader activityofHealth Promotion.

Contd..
• Some people viewed HE in a rather stereotypical way, reflecting a narrow
field of activityand focusingon the individual.
• HP, on the other hand has been positioned as the more politically correct
approach to challenginghealth status.

Health Promotion is thus seen as the umbrella term that includes
a whole range of activities, such as policy development,
environmental or social action and organisational development.
6/1/18
Concept of HP - Rakesh Singh

Approaches to Health Education
• HE is seen as a way of providing the public and in many cases risk groups
with information; this information is intended to motivate them to change
the behaviour that placed them at risk of developing a particular disease
or set of diseases.
• Diverse approaches to HE have emerged over the last century:
q The two most common- preventive approach and the educational
approach.
q A third approach has also been implemented - the empowerment
approach.

The Preventive Approach
• Aims to provide individuals with knowledge, facilitate a change in attitude and, if
successful, to galvanize the individual into action or into the practice of
preventive behaviours.
• The approach supports the use of a variety of persuasive communication
strategies, for example, mass media campaigns, or individual educational
sessions at a local clinic, to influence behaviour change.
• This approach has been criticised for assuming that knowledge leads to a change
in attitude.
Take the issue of a healthy diet for example: whilst I know that cream cakes and
donuts are unhealthy for me, I have not eliminated them from my diet. The same
could be said for smoking. As a health worker, I know smoking is bad for me and
that it has a negative impact on my health. However I am not planning to give up
smoking. Both examples illustrate that the relationship between knowledge,
attitude and behaviour change is not straightforward.

The Educational Approach
• Aims to provide individuals with understanding and knowledge, facilitate a
process of belief and value clarification, and develop and practise the skills to
make informed decisions.
• A key component of this approach is the recognition given to the value of
voluntarism, i.e. that individuals should be free to make their own decisions,
either now or at some future time, about their choice of action.
• This kind of approach would be suitable as a basis for running workshops
where individuals are or will be faced with havingto make a choice.
• For example, the approach could be used in the various stages of a smoking
cessation programme or in a dieting programme. It often includes a series of
value clarification workshops.

The Empowerment Approach
• This approach supports the idea of providing individuals with an opportunity
to critically reflect upon their environment, as they acquire knowledge, to
clarify their values and develop skills.
• This enables them to maximise their chances of managing the
environmental constraints - constraints over which individuals might find it
difficult to exercise some degree of control, if they did not have adequate
life skills.
• This approach is very much a bottom-up approach and is like the process of
communitydevelopment -with the health promoter as facilitator.
• An example- health promoter working with teachers to develop programmes
aimed at building the self-esteem of young girls, so that they are able to
actively participate in their studies and to enter into relationships with
greater self-confidence.

• HE models have been subject to a considerable amountofcriticism.
• Concerns have been raised about their individualistic approach and their
tendencytowards blamingthe victim.
• For instance, how empowered are individuals to receive and to act on health
education messages, when the context in which they live does not support
or allowfor the necessarybehaviour change?
• For example, it might be difficult for a teenager to stop smoking when
adverts glamorise smoking and there is pressure on young people to smoke
in order to fit into their peer group.

• Although HE has achieved some success in changing lifestyle, it has been
realised that changes in individual behaviour would not bring about the
necessary improvements or changes that are required to change patterns
of ill health or disease.
• Many of the changes that were required were beyond the power of the
individual.
• This is where the ideas of the New Public Health and Health Promotion
arose.
• Let us now take a few steps back and consider how this transition came
about and what other influences have shaped the course of Health
Promotion as we know it today.

HISTORY OF THE HEALTH PROMOTION

The Early Public Health Movement in Europe
• In Northern Europe, the Industrial Revolution (late 18th century in Britain),
and the growing popularity and attraction of cities resulted in massive
changes in population patterns and in the physical environment in which
people lived.
• However, this rapid industrialisation also brought with it disease and social
dislocation – the disintegration of family and social structures.
• In Britain, the overcrowded and unsanitary living conditions of the poor,
coupled with the rise of cholera and typhoid as major causes of death,
placed pressure on the government to introduce reforms or legislation to
promote public health.

Contd…
• In 1842, Edwin Chadwick, responsible for leading a “Health of Towns Commission”
and advocating for the first public health reforms, suggested that the ill health
experienced by the poor was a result of poor housing, sanitation and unclean
water.
• His efforts resulted in the 1848 Public Health Act, which gave local authorities the
powers to remedy unsanitary conditions and to require adequate drainage and
sanitation in towns.
• It was around this time (1854), John Snow discovered that cholera was a
waterborne disease, by tracing an outbreak to a water pump in Broad Street, Soho,
London. When use of the water pump was stopped, the outbreak stopped.
• Experiences such as these, together with public health legislation led to the
appointment of Medical Officers of Health by local authorities, to enforce public
health legislation and advise on appropriate measures.

• Opinions differ about whether this early public health movement evolved
out of a “desire to control disease and the poor who were seen to be the
cause of it, rather than by a more altruistic desire to make a society a
fairer place”.
• Some theorists believe that the sanitary reforms that were introduced
during this time were more about ensuring that the workforce was
economically active and could support an efficient capitalist economy than
about the redistribution of resources and better living conditions for the
poor.
• Altruism or control of the poor???

The rise in popularity of the Medical Model
• Motivations aside, at the end of the nineteenth century, the emphasis on
improving environmental and social conditions in order to prevent ill-
health was overshadowed by the rising popularity and investment in a
medical (or curative) approach to tackling ill-health.
• “As the most pressing environmental problems were brought under
control, action to improve the health of the population moved on first to
personal preventative medical services, such as immunization and family
planning, and later to a range of other initiatives including the
development of community and school nursing and school health services”.

Contd..
• Public health activity then entered a therapeutic era from the 1930’s, with
the advent of insulin (which treats diabetes) and simple antibiotics.
• Historically, this period was also characterised by “a weakening of
departments of public health and a shift of power and resources to
hospital-based services and particularly those based in teaching hospitals”.
• Underlying this therapeutic orientation was an “… implicit assumption
that magic bullets could be provided by the pharmaceutical industry for all
conditions”

Contd…
• This trend – that of placing greater emphasis and value on scientific
medicine rather than on social, political and environmental measures to
treat and prevent ill-health continued until the early 1970’s.
• You will recall that this is a medical model approach as opposed to a social
or Public Health model approach.
• During this era, medical advances claimed much of the credit for
extending life expectancy.
• After the Second World War “medical progress seemed to promise that it
would eventually be able to cure most diseases”.

Questioning the Medical Model
• The social climate of the 1960s and 1970s was characterised by protest,
activism and challenging of the status quo or existing conditions.
• Examples are the Vietnam War, issues of gender equality and the Women’s
Movement which were raised and protested about in public.
• In addition, during the early 1970s, many countries were experiencing a
crisis in health care costs.
• People began to consider that whilst medicine might be good against acute
illnesses like TB or pneumonia, it did not appear to have much to offer in
other areas such as cancer.
• The rates of cancer were still the same and there was still no cure for the
disease.
• Thus, value or returns from the investment in medical technology appeared
to be decreasing.

Contd…
• Studying the growth of the population in England and Wales, showed that,
apart from the smallpox vaccination, immunisation or medical therapies
were unlikely to have had a significant impact on mortality in the 19th and
20th centuries.
• Further, mortality was in fact declining before effective medical
interventions were available.
• When ranked the major contributing factors to improvements in health in
order of importance.... “…limitation in family size (a behavioural change),
increase in food supplies and a healthier physical environment
(environmental influences) and specific preventive and therapeutic
measures”.

Contd…
• Interventions from government authorities were critical in enabling health
to be improved.
• Collectively, it was established that there was importance of general
standards of living and of state intervention in improving the health of
populations - crucial ideas underpinning the new Public Health
Movement.

The New Public Health Movement
• The Lalonde Report is the first major landmark in what came to be known as
the New Public Health era.
• In 1974, the Canadian Minister of National Health and Welfare, Marc
Lalonde,publisheda report entitled A New Perspective on the Health.
• This report suggested that greater emphasis should be attributed to the
environment and to behavioural factors as causes of disease and death,
rather than biophysical characteristics.
• This was a major change from the Medical Model:in what way did it differ?

Contd…
• The Lalonde report described four health fields as having an influence on
health and illness:
1. Medicine and health care services.
2. Lifestyle or behavioural factors.
3. The environment.
4. Human biology.

Contd…
• Also proposed that critical improvements within the environment,
combined with changes in behaviour could lead to significant reductions in
morbidityand mortality.
• This report is viewed by some as a highly significant watershed in that it
“… signalled the turning point in efforts to rediscover public health in
developed countries”. It did so by proposing that policies focus more on
the preventionofillness than on treatment and cure.
• Many people consider this report as marking the beginning of the New
Public Health Movement.

A focus on lifestyle
• Even though the Report broke with the Medical Model, the particular
focus on individual behaviour or lifestyle was seen by some as cause for
concern.
• The focus was criticised because it was seen as narrow, failing to take into
account the impact of social forces (e.g. peer influences, commercial
marketing and the price of commodities)on behavioural choices.
• As a result, the approach tended to ignore an individual’s social
environment,or the context in which decisions were being made.
• Greater emphasis was placed on individual responsibility. This led to the
idea of self-imposed risk in relation to health.
• In other words, people placed themselves at risk of ill-health through their
choice of behaviour, e.g. drinking alcohol, taking drugs, getting pregnant
unintentionallyand catchingSTDs.
Contd…

Contd…
• HP programmes based on the approach of the Lalonde Report would have
focused on persuading people to change their health-related behaviour, which
placed them at risk of disease.
• This focus on lifestyle was characteristic of the 1970s and brought about
different approaches to creating change in individual behaviours.
• These approaches drew almost exclusively on psychological theory, with little
regard for the individual’s social and economic circumstances.
• Well known behaviour change models such as the Health Belief Model, the
Theory of Reasoned Action and the Social Learning Theory were developed
during this time.

Contd…
• Parallel with this behavioural approach to Health Promotion, there was an
increasing understanding of the structural causes of illness and health: in
other words, those who did not subscribe to the ideas of Lalonde’s
approach were developing one which took account of those causes that fell
outside the control ofthe individual.
• In line with this understanding, two significant WHO events occurred in the
late 1970’s, which shaped the development ofHealth Promotion.
q World Health Organisation: Global Strategy for Health for All by the Year
2000 (1977), and the International Conference on Primary Health Care,
Alma-Ata (1978)

Contd…
• In 1977, 30th WHA decided that the main health-related goal of
governments and WHO in the coming decades should be directed at
ensuring that all the people of the world attain a level of health that
would permit them to lead socially and economically productive lives
(Global Strategyfor Health for All by the Year 2000 -HFA 2000).
• This global strategy was adopted in 1981 by 34th WHA and thereby
accepted as WHO policy.
• Member states of the WHO were invited to formulate their national
policies, strategies and plans of action for attaining this goal and to act
collectivelyin formulatingregional and global strategies.

Contd…
• The significant feature of HFA 2000 was the recognition that the main
determinants of health lay outside the health sector - namely food, water,
sanitation,housing,employment etc.
• This implied a global movement in which inequities between as well as within
countries could be reduced.

Contd…
• In 1978, the International Conference on Primary Health Care at Alma-Ata
defined the key to achievingthe goal of HFA 2000 as Primary Health Care.
• The Declaration on Primary Health Care at Alma-Ata was an important
milestone in the development ofcurrent concept of Health Promotion.
• In the early 1980’s, some of the key principles of the Primary Health Care
approach such as equity, community participation, a focus on prevention
and the need for multi-sectoral activity, were being incorporated into
international discussions about a new concept – that of Health Promotion.
• Community participation or community involvement in health
development is central to any discussion which focuses on Health
Promotion.

Principles of HP
• The WHO later convened two working groups that focused on Health
Promotion.
• First, in 1984, a WHO working group met in Copenhagen and drew up an
outline of the most important issues facing the development of Health
Promotion policies and programmes. Arising from this, the WHO made
explicit five key principles for Health Promotion:
1. Involves the population as a whole in the context of their everyday lives,
rather than focusing on people at risk of specific diseases.
2. Directed towards action on the causes or determinants of health, to ensure
that the total environment, which is beyond the control of individuals, is
conducive to health.

Contd…
3. Combines diverse but complementary methods or approaches, including
communication, education, legislation, fiscal measures, organisational
change, community development and spontaneous local activities
against health hazards.
4. Aims particularly at effective public participation, supporting the
principle of self-help movements and encouraging people to find their
own ways of managing the health of their community.
5. While Health Promotion is basically an activity in the health and social
fields and not a medical service, health professionals, particularly in
Primary Health Care have an important role in nurturing and enabling
Health Promotion.

Contd…
• In relation to these principles, the WHO noted that improvements in
lifestyles, environmental conditions and health care will have little effect if
fundamentalconditions are not met.
• These conditions include peace or freedom from war, equality, satisfaction
of basic needs,political commitment and publicsupport.

International Conference on Health Promotion,
Ottawa, Ontario, Canada (1986)
• Conference produced a critical document - the Ottawa Charter for Health
Promotion.
• Many of the principles outlined by the WHO in their earlier working group
were developed further in the Ottawa Charter.

• The Ottawa Charter outlined five areas in which Health Promotion action
should be directed:
1. Buildinghealthypublicpolicy.
2. Creatingsupportive environments.
3. Strengtheningcommunityaction.
4. Developingpersonal skills.
5. Re-orientinghealth services.
• It identified three ways (or strategies) in which health could be promoted,
namelythrough:
1. Advocacy
2. Enablement
3. Mediation

Contd…
• The Charter notes that HP strategies and programmes should be adapted
to the local needs and that the differing social, cultural and economic
systems within countries and regions should be taken into account when
developingprogrammes.
• The Conference tended to focus more on the needs of the industrialised
countries,rather than developingcountries.
• Alma Ata had a sense of abundance about it, Ottawa was characterised by
restraint, reflecting the climate of the times in which the Charter was
drafted.
• The Charter has however been used worldwide as the basic framework
around which Health Promotion activities are planned and is regarded as
“...something of a mantra [or a set of guidelines] for health promotion
workers”.

Pre-requisites of Health (Promotion)
1. Peace
2. Shelter
3. Education
4. Food
5. Income
6. A stable eco-system
7. Sustainable resources
8. Social justice
9. Equity

TASK 13 – Based on Ottawa Charter for Health Promotion
a) Why is it important for health workers in developing countries to be
aware of the prerequisites for health?
b) How are these prerequisites for health linked to the principle of
inter-sectoral collaboration proposed in the declaration of Alma
Ata?
c) What do the verbs to “advocate”, “enable” and “mediate” mean?
d) What are some practical everyday examples of these three
strategies or tools of Heath Promotion – “advocacy”, “enablement” and
“mediation”?

Feedback
• The Charter is based on the belief that a secure foundation in society- the
fundamental conditions of “peace, shelter, education, food, income, a stable
eco-system, sustainable resources, social justice and equity” - are
prerequisites for health improvement.
• Working in the context of a developing country, it is important for HP workers
to reflect on the extent to which such prerequisites exist, and how these
might affect the success or the outcome of HP interventions.
• These prerequisites are linked to the principle of inter-sectoral collaboration,
which is a way of helping to secure these conditions. This connection is
summarised in the followingquote:
“Health cannot be achieved by the health sector alone. In developing
countries in particular, economic development, anti-poverty measures, food
production, water, sanitation, housing, environmental protection and
education all contribute to health and have the same goal of human
development”(WHO-UNICEF, 1978: 40).

Contd…
• To advocate means to speak in favour of something or to recommend it.
• To enable means to provide the means or the ability to do something.
• To mediate means to negotiate between opposing sides.

Contd…
Examples of advocacy include:
• Petitions drawn up by groups of people in response to a particular issue
e.g. the lack of adequate protection provided to a community by the
police service or the number of rapes occurring within a region or country.
• Demonstrations e.g. a group of bus drivers and owners protesting outside
of parliament about current transport legislation that restricts their
business.

Contd…
Examples of enablement include:
• Trainingprogrammes and workshops.
• Representative meetings e.g. all stakeholders involved in running a health
clinic.
Examples of mediation include:
• Reaching agreement around co-ordinated action e.g. where the Health
and Education Departments work together to develop health promoting
schools within a local district.
• Two parties coming to an agreement whereby individual interests are set
aside in the interests of the health of a community e.g. after a meeting
with the health department, a trucking company agrees to review their
policy around the length of time drivers spend away from home and
agrees to support an educational intervention for their long-distance
drivers.

Strategies of health promotion
Advocacy
• Involves a process of pressurisingor pushingfor change.
• Usually aimed at changing policies, laws or regulatory measures that either
work against the development of optimal health or fail to protect the health
of individuals and communities.
• Often seen as a process of representing the rights or needs of marginalised
groups such as street children, sex workers, people suffering from a
particular health condition,or poor communities.
• Collaborative process, gives a voice to the needs of a community and brings
these needs to the attention of appropriate decision-makers, or those that
have the power to change the unhealthy policies.

Contd…
• Communication is an important component ofthe advocacy process.
• Communication strategies include:
1. Interacting and engaging with the mass media, so as to profile the
campaign and shape public debate around the problem that the campaign
is addressing.
2. Producing and distributing educational media about the issue or the
problem.
3. Networking with others in order to develop support for the campaign
which often gives rise to the development ofcoalitions.

ADVOCACY VS LOBBYING???

Advocacy VS Lobbying
• Advocacy is generally used to describe the broad range of activities that
one would do to influence change.
• Lobbying refers to the specific work one would do to influence key
decision-makers (like parliamentarians and local councillors).
• It is suggested that the word lobbying came to be used like this because
advocates would spend many an hour waiting in the parliamentary lobby
in order to catch up and meet with parliamentarians!

Enablement
• Enablement is a wayof workingwith others in a participative manner.
• It is a process that encourages people to reflect on their own experiences
and facilitates a process of learning and skills-building, which people can
applyto their everydaylives.
• The Ottawa Charter links enablement with equity(or fairness)in health.
• For example, if we develop capacity or increase the skills of individuals or
groups, be they health workers or members of the community, they will
have more power to control the factors that determine their health.

Mediation
• Mediation is a way of coming to an agreement, of seeking reconciliation,
of settingaside individualinterestsand negotiatinga common goal.
• The Charter links the term mediation to co-ordinated action between
different players – a concept that is often referred to when we talk about
inter-sectoral action.
• The motivation behind working together is that co-operation produces
greater output than competition.

ASSIGNMENT 1 – Analyse HP projects in terms of the Ottawa Charter
Look at the five areas of action and the three strategies in the Ottawa
Charter.
Think about a project in your own context, and analyse and Classify each
project or initiative intothe five areas of action and the three strategies.

Feedback
• In reality, it is difficult to distinguish into which particular action area a
Health Promotion project falls or which particular strategy you are using or
working with as a health promoter.
• Inevitably the processes involved in one action area overlap with the work
we do in another other area.
• Very often we find we are working with all three strategies.
• For example, in the process of developing a community campaign
(advocacy), we often have to develop people’s skills or capacity in a
particular area (enablement) and to facilitate agreement between the
different parties involved in the campaign issue (mediation).
• The important point in this exercise is to realise that for a Health Promotion
project to be successful, it cannot work exclusively in one action area alone.
There is a greater chance of change occurring if consideration is given to
working across a range of areas of action.

• Following the development of the Ottawa Charter, the WHO convened a
second Working Group on Health Promotion in Developing Countries in
Geneva in October 1989.
• The task of this group was to explore the application of Health Promotion
concepts and strategies to developing countries and to recommend
specific steps for translatingthese into action.

A CALL FOR ACTION
• The summary statement produced by the working group meeting
(convened by the WHO in 1989) for developing countries is called A Call for
Action: Promoting Health in Developing Countries (WHO, 1991). It focuses
on four main themes:
1. Issues (which are often in the form of challenges), that need to be
considered in the field of Health Promotion.
2. The importance ofworking together to develop healthypublicpolicies.
3. Supportinggrass-roots strategies.
4. Strengthening political commitment to and national capability for Health
Promotion.
• The statement proposed that: “Immediate and sustained action is called for
now in all nations,to move health promotion from concept to reality”.
• Although developed over two decades ago, this document still provides a
useful overview of some of the key issues that need to be considered in
relation to Health Promotion in a developingcontext.

The HP Emblem
• Represents a circle with 3 wings
• The main graphic elements of the HP logo are:
1. one outside circle,
2. one round spot within the circle, and
3. three wings that originate from this inner spot, one of which is breaking the
outside circle.
a. The outside circle, originally in red colour, is representing the goal of “Building
Healthy Public Policies”, therefore symbolising the need for policies to “hold
things together”. This circle is encompassing the three wings, symbolising the
need to address all five key action areas of health promotion in an integrated
and complementary manner.
b. The round spot within the circle stands for the three basic strategies for health
promotion, “enabling, mediating, and advocacy”
c. The three wings represent the five key action areas for health promotion that
were identified in the Ottawa Charter for Health Promotion in 1986 and were
reconfirmed in the Jakarta Declaration on Leading Health Promotion into the
21st Century in 1997.

Contd…
More specifically:
• The upper wing represents that action is needed to “strengthen community
action” and to “develop personal skills”. This wing is breaking the circle to
symbolise that society and communities as well as individuals are constantly
changing and, therefore, the policy sphere has to constantly react and
develop to reflect these changes: a “HealthyPublic Policy” is needed;
• The middle wing represents that action is needed to “create supportive
environmentsfor health”
• The bottom wing represents that action is needed to “reorient health
services” towards preventingdiseases and promotinghealth.
• Overall, the logo visualises the idea that HP is a comprehensive, multi-
strategyapproach.

Recent Developments in Health Promotion

The Second International Health Promotion
Conference
• Held in Adelaide, Australia (1988).
• Focused on the theme of healthy public policy.
• At this conference, the DG of the WHO at that time explained that the
main aim of developing healthy public policies was to create the
preconditions for healthy living through:
q closing the gap between social groups and between nations;
q broadening people’s choices to make healthy their choices the easiest and
most possible, and
q ensuring supportive social environments.
• The importance of community participation and collaboration between all
sectors of government were emphasised as crucial aspects of healthy
public policy.

The Third International Health Promotion
Conference
• Held in Sundsvall,Sweden in 1991.
• Focused on linkingenvironmentalissues directlyto human health.
• Emphasised that Health Promotion has been, and should be concerned
with preservingand protectingnatural environments.
• An important link was thus made at this international conference between
those activities concerned with the promotion of health within
communities and those activities that focus on protecting the natural
environment.

United Nations Conference on Environment
and Development (The Earth Summit)
• Held in Rio de Janeiro,Brazil in 1992.
• One of the outcomes of this conference was the development of a detailed
action plan outlining how member states could work towards sustainable
development.
• By sustainable development they meant development which meets the
needs of the present without compromising the ability of future
generations to meet their own needs.
• The action plan specifically highlights the role of local government in
achievingthis sustainability.

The Fourth International Health Promotion
Conference
• Held in Jakarta,Indonesia in 1997.
• First time it had been held in a developingcountry.
• Focused on identifying directions and strategies to address the challenges of
promotinghealth in the 21st Century.
• The main outcome of the conference was the Jakarta Declaration.
• In the Declaration, emphasis was placed on the importance of developing
new alliances and partnerships, for example between private and public, and
within government and non-government agencies.
• In addition,the declaration adopts a settings approach to Health Promotion.
• Settings refers to an approach to Health Promotion that focuses on a place
or a setting in which people gather, such as a school or a workplace, as
opposed to an illness or symptom.
• Health promoters were urged to build new alliances for health, including
private sector partnerships.

Contd…
• In practice, this could mean that the local government structure, in
collaboration with the local community, identifies the major social,
economic and environmental issues that are going to pose substantial
risks to the environment and to publichealth.
• They then develop an integrated action plan to address the key issues,
both in the short and long term.
• Another approach might be for all stakeholders to identify key
environmental and public health goals that they would want incorporated
into the local government management plans, such as accessing
affordable housing, improving public transport, and ensuring community
safety.

Priorities identified by JD
1. Promote social responsibilityfor health
2. Increase investments for health development
3. Consolidate and expand partnerships for health
4. Increase communitycapacityand empower the individual
5. Secure an infrastructure for health promotion

The Fifth Global Conference on Health
Promotion
• Took place in Mexico City from the 5-9th June 2000.
• It was entitled Bridging the Equity Gap.
• It had the followingobjectives:
q To show how Health Promotion makes a difference to health and quality
of life, particularlyfor those livingin adverse conditions.
q To place health high on the development agenda within international,
national and local agencies.
q To stimulate partnerships for health between different sectors and at all
levels of society.

Brainstorm
• In terms of the June 2000 HP conference,what is the significance of:
a) The switch to calling it a “global” rather than an “international”
conference?
b) The conference objectives and what they suggest about the future
direction ofHP?

Feedback
a) The term “global” signifies that the conference is now bigger in scope,
involvingcountries from all over the world,rather than just some nations.
b) The conference objectives do not, however, introduce an entirely new
agenda for HP. Instead theystress new priorities:
• The role of HP in promoting development at all levels, particularly with
regard to poor countries.
• CollaborationaroundHP at all levels.

• The Bangkok Charter for HP (Thailand), 2005: New Context, Globalization
(advocate for health based on human rights, invest in sustainable
policies, actions and infrastructure, build capacity for policy development,
leadership, HP practice, knowledge transfer and research, and health
literacy; regulate and legislate to ensure a high level of protection,
partner and build alliance to create sustainable actions).
• Nairobi, 2009: Bridging the implementation gap (multiple participatory
processes, urgency to close the implementation gap in health and
development through HP, importance of HP as an integrative, cost-
effective strategy, and as an essential component of health systems
primed to respond adequatelyto emergingconcerns).
Further Discourse in HP

Contd…
• Helsinki, Finland, 2013: Theme: Health in all policies (Inter-sectoral action
– action beyond health sector; its focus was on implementation, the “how-
to”).
• Shanghai, 2016: (health and wellbeing are essential to achieving
sustainable development, Good governance is crucial for health, Cities and
communities are critical settings for health, Health literacy empowers and
drives equity, accelerate the implementation of the SDGs through
increased political commitment and financialinvestment in HP)

ASSIGNMENT 2 – Assess the role of the private sector as outlined in the Jakarta
Declaration
Read the Jakarta Declaration on Health Promotion into the 21st Century:
a) What role you think the private sector or the sector which works for profit
could playin a Health Promotion project at a local or district level?
b) What do you think some of the difficulties might be in working with the
private or business sector at a local level?

Feedback
• If you are developing or managing a Health Promotion project at a local level,
it is likely that you would set up a steering committee or an inter-sectoral
team to co-ordinate the project.
• Like other role players in the district, a representative from the private sector
or business sector would be a member of this committee.
• Together the team would develop the vision for the project and start defining
project objectives and activities. A private sector representative might be
able to contribute to the project by:
q Providing resources such as a meeting space for the group and a venue for
workshops, covering the costs of printing materials or minutes of the
meetings.
q Providing skills and training in relation to project design and development,
such as strategicplanningprocesses or budgeting.
q Providing contacts and links with other businesses or private sector
institutions or networks.
q Supporting the implementation of the project on the ground e.g. by providing
the commitment and resources to implement the Health Promotion project
within their respective workplaces.

Contd…
• Some of the potential problems might be that private sector
representatives:
q Have less time to commit to the development ofthe project.
q Stipulate that there are specific requirements attached to the resources
they contribute to the project or the development process.
q Might have a different understandingofthe concept of Health Promotion.
q Might be pressurised to produce noticeable or tangible results from the
project early on in the process, thus reducing the level of community
involvement.

A Framework for Health Promotion Activities

Preventive Health Services
• These include medical services, which aim to prevent ill-health through
immunization, family planning and personal health checks, as well as
wider preventive health services such as child protection services for
children at risk of child abuse.

Community-based work
• This is a “bottom up” approach to Health Promotion, working with and for
people.
• It involves communities in health works such as local campaigns for better
facilities.
• It includes community development, which is essentially about
communities identifying their own health needs and taking action to
address them.

Organizational development
• This is about developing and implementing policies within organisations to
promote the health of staffand customers.
• Examples include implementing policies on equal opportunities or
providinghealthyfood choices in staffdiningrooms.

Healthy public policies
• This involves statutory and voluntary agencies, professionals and the
publicworkingtogether to develop changes in the conditions ofliving.
• It is about seeing the implication for health in policies associated with
housing,employment,transport and leisure.

Environmental health measures
• This is about making the physical environment conducive to health,
whether at home, work or in publicplaces.
• It includes traditional public health measures such as providing clean food
and water, controlling pollution, as well as working on newer issues such
as providing smoke free areas in pubs or taverns and controlling the use of
environmentallydamagingchemicals.

Economic and regulatory activities
• This includes political and educational activity directed at politicians,
policymakers and planners.
• It involves lobbying for and implementing legislative changes, such as food
labelling regulations and advocating for financial measures such as an
increase in tobacco legislation.

Health education programmes
• These are planned opportunities for people to learn about health and to
undertake voluntarychanges 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.
• They can happen on a one-to-one level such as health worker to client
sessions, in a group, or by means of reaching large audiences through the
mass media and health exhibitions.

Concept of Health Promotion

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