Health Promotion And Health Education

DR NATASHA K (MBBS, MPH, PHD FELLOW)ASST PROF BUHSDRNATASHA1976@GMAIL.COM

Lecture 1INTRODUCTION TO HEALTH PROMOTION

2

Topics Historical Background, Concept, Philosophy, Definition, Process,

Theory & Scope, Framework, Principles, Approaches & Aims, and Objectives of Health Promotion.

Ottawa Charter, Bangkok Charter and global development of Health Promotion.

Health promotion priority areas and strategies

3

Background of Health Promotion The world at the beginning of the 21st century is a world of change. Politically economically,

technically, socio-culturally and demographically, countries and communities are in transaction. The world is significantly different today from some decades ago. New situations pose new

problems and at the same time present new opportunities. New health promotion approaches are required to match them. Health promotion has to be

justified against competing claims for the societies resources. We must strive to find even more effective ways of promoting supporting environments,

strengthening communities refocusing services and helping people acquire knowledge and skills for health.

We need to explore the strategies and methods for effectiveness of these activities.

4

Background cont… The information technology of today and tomorrow can enhance the ability of health promotion to

reach people everywhere. This however will require creativity and imitativeness, as well as commitment to policy making. Achieving health for all, with the participation of all, based on the principles of equity and solidarity, requires not only good management but a fresh approach.

Over the past years stretching from Ottawa (1986), the first International Conference on Health Promotion and which gave its name to Ottawa Chatter from Health Promotion, to the second conference in Adelaide (1988) and the third in Sundsvall (1991), Health Promotion has carried its mission of giving health a high position on the political agenda.

Each of these conference has made a significant contribution to public health and to focusing our attention to the necessity for a more holistic & comprehensive approach to addressing the determinants of health. Jakarta conference is the fourth in a series of technical conferences on health promotion, all of which have and continue to make major contributions to health promotion & public health.

5

History The “first and best known” definition of health promotion, declared by the American

Journal of Health Promotion since 1986 is “the science and art of helping people change their lifestyle to move

toward a state of optimal health” Since then and even before there have been plenty of definitions for health

promotion 1974 Lalonde Report form Canada 1979 Healthy People report of Surgeon general of united states 1984 WHO 1986 Canadian minister of national health and welfare

6

☼ Different conferences, important documentations and charters

7Health promotion is directed towards action on the determinants or causes of health promotion, therefore, requires a close co-operation of sectors beyond health services, reflecting the diversity of conditions which influence health.

Concept

Government at both local and national levels has a unique responsibility to act appropriately and in a timely way to ensure that the ‘total’ environment, which is beyond the control of individuals and groups, is conducive to health.

8Concept

What is Health Promotion? Today Health Promotion is more than personal and population education.Defined in a number of ways “The process of enabling people to increase control over and improve their health”

(World Health Organisation 1986)

Health Promotion = health education x healthy public policy.

(Tones and Tilford, 1994)

9

Phylosophy

Through the involvement of home, school and community,

including: the physical, intellectual, emotional, social and moral development

Health promotion is any combination of health, education, economic, political, spiritual or organisational initiative designed

to bring about positive attitudinal, behavioural, social or environmental changes conducive to improving the health of populations.

10

Definition Definition (learn this one)(learn this one)

Health promotion is the process of enabling people to increase control over, and to improve, their health. It is a positive concept emphasising personal, social, political and institutional resources, as well as physical capacities.

WHO (1990), Health Promotion Glossary

11

THE PROCESS OF HEALTH THE PROCESS OF HEALTH PROMOTIONPROMOTION

FOCUS STRATEGIES IMPACT OUTCOMES

Individuals

Groups

Population

Education couselling

Economic change

Legislative change

Policy or organisation change

Behavioural educational change

Social, economic and environment change

Better Health

Quality of life

12

The scope of health promotion activity Frameworks and Models are tools that help explain phenomena. Many tools developed to explain the scope of health promotion. 1.Beattie’s (1991) model of health promotion 2.Tones and Tilford’s (1994) empowerment model of health promotion3.Caplan and Holland’s (1990) Four perspectives on health promotion 4.Naidoo and Wills (2000) typology of health promotion

13

Health promotion theories

There are many different theories that guide health promotion interventions

Most theories are based in the social sciences including sociology, education, psychology and policy studies

Different approaches to health promotion tap into different theoretical perspectives and academic disciplines

We will examine 4 contrasting models

14

Niandoo & Wills 2005 Models of health promotion may help to:

Conceptualize or map the field of health promotion Interrogate and analyze existing practice Plan and chart the possibilities for interventions

15

Beattie’s model of Health Promotion

Individual

Authoritative

Collective

Negotiated

Health persuasion Needs to focus on why behaviour is

happening

Legislative Action FocusAct

Resources Policy

Community Development Empowerment

community levelSkills

Personal CounsellingGreater control

16

Beattie’s model appliedKey features Examines 2 axis i) type of approach used top down (authoritarian) or bottom up (negotiated or owned by clients) ii) size of approachCategorises 4 types of activities a)Personal Counselling eg working with dietician on food and physical individual personal plans and goalsb)Health persuasion eg Campaign of eating 5 fruit and vegetables a day on TVc)Legislative action eg laws that subsidise the price of healthy food stuffd)Community development eg communities producing and distributing food themselves

17

Tones and Tilford’s (1994) model of health promotion

Key featuresStates interaction between two main sets of processes for health improvement i)development and implementation of healthy public policy ii) health education in which people are empowered to take control of their life.Example attempts of Jamie’s School Diners campaign where school meals was brought into public consciousness and lead to standards for meals and an increase in the budgets for school meals.Only when these two approaches work in parallel can the conditions for living and individuals behavioural aspects of health be addressed

18

Caplan and Holland’s model of health promotion (1990)

Key features

More complex and theoretically drivenAttempts to unpick what determines health and ill-health and therefore what activities can be used to address health issues. One axis refers to a theory of knowledge and how knowledge is generated in relation to healthThe other axis refers to how society is constructed and how this impacts on health.

19

TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE et al – 1990)

Health education

Prevention Health protection

12

34

5

76

1. Preventive services, e.g.. immunization, cervical screening, hypertension case finding, developmental surveillance, use of nicotine chewing gum to aid smoking cessation.

2. Preventive health education, e.g.. smoking cessation advice and information.

3. Preventive health protection, e.g.. fluoridation of water.

4. Health education for preventive health protection, e.g.. lobbying for seat belt legislation.

5. Positive health education, e.g. life skills with young people.

6. Positive health protection, e.g.. workplace smoking policy.

7. Health education aimed at positive health protection, e.g.. pushing for a ban on tobacco advertising.

20

TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE et al – 1990) (cont.)

Shows how these different approaches relate to each other in an all-inclusive process termed health promotion.

Health education- communication to enhance well being and prevent ill health through influencing knowledge and attitudes.

Prevention- reducing or avoiding the risk of diseases and ill health primary through medical interventions.

Health protection safeguarding population health legislative, fiscal or social measures.

21

A FRAMEWORK FOR HEALTH PROMOTION A FRAMEWORK FOR HEALTH PROMOTION ACTIVITIESACTIVITIES

AREAS OF HEALTH PROMOTION ACTIVITY

Preventive healthservices(Primary, secondary, tertiary

Community-based work

OrganisationdevelopmentHealthy

Public Policy

Environmentalhealth measures

Economic and regulatory activities

Health educationprogrammes

22

A FRAMEWORK FOR HEALTH PROMOTION A FRAMEWORK FOR HEALTH PROMOTION ACTIVITIESACTIVITIES

CLASS

AGE

GENDER

ETHNICITY

Housing tenure

Environment

Regional location

Access to healthservices

Access to leisurefacilities

Nutrition

Smoking

Physicalactivity

Psychosocialfactors, e.g.stress

Cholesterol

Bloodpressure

Obesity

KEY SOCIALSTRATIFICATIONFACTORS

ENVIRONMENTFACTORS

LIFESTYLEFACTORS

PHYSIOLOGICALFACTORS

C

H

D

23

24The five key principles of health promotion as

determined by WHO are as follows:1.Health promotion involves the population as a whole in the context of their everyday life, rather than focusing on people at risk from specific diseases.2.Health promotion is directed towards action on the determinants or causes of health therefore, requires a close co-operation of sectors beyond health services, reflecting the diversity of conditions which influence health

PRINCIPLES OF HEALTH PROMOTION

25PRINCIPLES OF HEALTH PROMOTION contd

3. Health promotion combines diverse, but complementary methods or approaches including communication, education, legislation, fiscal measures, organisational change, community change, community development and spontaneous local activities against health hazards.4. Health promotion aims particularly at effective and concrete public participation. This requires the further development of problem-defining and decision-making life skills, both individually and collectively, and the promotion of effective participation mechanisms.

5. Health promotion is primarily a societal and political venture and not medical service, although health professionals have an important role in advocating and enabling health promotion.

Main approaches to health promotion

Medical or preventative Behavioral change Educational Empowerment Social change

26

Aims Reduce morbidity and premature mortality Target: whole populations or high risk groups Promotion of medical intervention to prevent ill-health

27The medical or preventative approach

Aims Encourages individuals to adopt healthy behaviors which improve health Views health as a property of individuals People can make real improvements to their health by choosing to change lifestyle It is people’s responsibility to take action to look after themselves Involves a change in attitude followed by a change in behavior

28Behavior change approach

Aims To enable people to make an informed choice about their health behavior by providing knowledge and information developing the necessary skills

Not similar the behavioral approach, it does NOT try to persuade or motivate change in a particular direction

OUTCOME is client’s voluntary choice which may be different from the one preferred by health promoter

29The educational approach

Empowerment approach 30

WHO defined health promotion as “enabling people to gain control over their lives” (empowerment)

Aims Helps people identify their own concerns and gain the skills and confidence necessary

to act upon them This is the only approach to use a ‘bottom-up’ (rather than ‘top-down’) approach Empowerment may involve both self-empowerment and community empowerment Self-empowerment:

Based on counseling Uses non-directive ways Increase person’s control over his/her own live

Aims (Cont.)

For people to be empowered they need to:1. Recognize and understand their powerlessness2. Feel strongly enough about their situation to want to change it3. Feel capable of changing the situation by having information,

support and life skills

31

Aims Radical approach which aims to change society not individual behavior Aims to bring changes in the physical, economic and social environment Healthy choice to become the easier choice in terms of cost, availability and

accessibility Targeted towards groups and populations

32Social change approach

These approaches have different objectives

To prevent disease To insure that people are well informed and are able to make

health choices To help people acquire the skills and confidence to take greater

control over their health To change polices and environments in order to facilitate healthy

choices

33

TOP-DOWN VS. BOTTOM-UP

Priorities set by health promoters who have the power and resources to make decisions and impose ideas of what should be done

Priorities are set by people themselves identifying issues they perceive as relevant

34

THE FIVE APPROACHESEXAMPLES RELATED TO SMOKING Based on Ewles and Simnet (1992:

36)

35

The medical approach

AIM: Free from lung disease, heart disease and other smoking related disorders

ACTIVITY: Encourage people to seek early detection and treatment of smoking related disorders

36

Behavioral change approach

AIM: Behavior changes from smoking to not smoking

ACTIVITY: Persuasive education to – prevent non-smokers from starting to smoke– persuade smokers to stop

37

Educational approach

AIM: Clients understand effects of smoking on health and will make a decision whether to smoke or not and act on their decision

ACTIVITY: Giving information to clients about effects of smoking Helping them explore their values and attitudes and come to a

decision Helping them learn how to stop smoking if they want to

38

The empowerment approach

AIM: Anti-smoking issue is considered only if clients identify it as a concern

ACTIVITY: Clients identify what, if anything, they want to know and do about it

39

Social change approach AIM: Make smoking socially unacceptable so it is easier not

to smoke than to smoke

ACTIVITY– No smoking policy in all public places– Cigarette sales less accessible– Promotion of non-smoking as a social norm– Limiting and challenging tobacco advertisements and sports sponsorships

40

Models

1. The medical model 2. The behaviour change model 3. The educational model 4. The empowerment model 5. The social change model

41

Break… BACK TO THE ‘BACK’…..AGAIN

42

Alma Ata Declaration, 1978

On Primary Health Care: Essential health care that’s practical, scientifically sound and social acceptable methods and technology made UNIVERSALLY accessible and affordable to individuals and families in the community.

It expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world.

43

Important Policy Documents 44 First ICHP Ottawa, Canada 1986 Resulted in the “Ottawa Charter for Health Promotion” Second ICHP Adelaide, Australia 1988 Resulted in the “Adelaide Recommendations on Healthy

Public Policy” Third ICHP Sundsvall, Sweden 1991 Resulted in the “Sundsvall Statement on Supportive

Environments for Health” Fourth ICHP Jakarta, Indonesia 1997 Resulted in the “Jakarta Declaration on Leading Health

Promotion into the 21st Century” Fifth GCHP Mexico City, Mexico 2000 Resulted in the “Mexico Ministerial Statement for the

promotion of health” Sixth GCHP Bangkok, Thailand 2005 Resulted in the “Bangkok Charter for Health Promotion in

a Globalized World” 7th Global Conference on Health Promotion: Nairobi 2009 8th Global Conference on Health Promotion: Helsinki 2013

Ottawa Charter (1986)

Health promotion should be a part of public policy, documents and measures.Health promotion should be a part of a community policy and practice.Environment should enable and promote health.People should be able to gain information, knowledge and skills enabling

development of health.Health services should more orient on health promotion and support.

45

THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

Healthy public policy is a pre-requisite for successful health promotion.

A Healthy Public Policy is characterized by a concern for health and equity and

an accountability for health impact.

Health should be made a priority item on the agenda of policy-makers in all

sectors.

Policy-makers should be made aware of the health consequences of their

decisions. They should create pro-health policies, whether in the area of

development, legislation, taxation etc.

1. Healthy Public Policy46

Healthy public policy covers a combination of diverse but complementary

measures and approaches such as legislation, taxation, fiscal incentives and

disincentives, policy analysis and review, and organizatioanl change Joint action by all sectors will contribute to achieving safer and healthier goods

and services, healthier public services, and cleaner and more healthy

environment. The aim is to make the healthier choice the easier choice for all people. HPP should lead to the creation of a supportive environment to enable people to

lead healthy live

1. Healthy Public Policy47THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

According to the Adelaide Conference (1988), “The main aim of HPP is to

create a supportive environment to enable the people to lead healthy lives.

Healthy choices are thereby made possible and easier for citizens”.

All relevant government sectors like agriculture, trade, education, industry and

finance need to give important consideration to health as an essential factor

during their policy formulation.

1. Healthy Public Policy

48THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

A supportive environment is essential for health.

Supportive environments cover the physical, social, economic, and political environment.

Supportive environments encompass where people live, work and play. This is what is envisaged by the “settings” approach.

Everyone has a role in creating supportive environments for health.

2. Create Supportive Environment49THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

According to the Ottawa Charter, “health promotion works through concrete and

effective community action in setting priorities, making decisions, planning

strategies and implementing them to achieve better health”.

There are many ways of defining community. Factors used are geography, culture

and social stratification.

Community action is any activity undertaken by a community in order to effect

change (including voluntary and self-help services).

3. Strengthen Community Action: Community Participation50THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

Community participation covers a spectrum of activities At the low end, it may be token participation in the form of consultation or

endorsing plans drawn up by the health authorities. At the high end, it may

be in the form of ‘people power’ where they have full say in identifying needs,

setting priorities, planning strategies and activities and implementing the

programme.

51THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

3. Strengthen Community Action: Community Participation

Full community participation occurs when communities participate in equal

partnership with health professionals as stakeholders in setting the health

agenda. Community participation is a social process whereby groups with shared

needs living in a defined geographic area actively pursue identification of their

needs, take decisions and establish mechanisms to meet these needs

3. Strengthen Community Action: community Participation52THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

According to the Jakarta Declaration (1997), “health promotion improves both

the ability of individuals to take action, and the capacity of groups,

organizations or communities to influence the determinants of health”.

Empowerment is an important strategy, based on the notion that health is

significantly affected by the extent to which one has control or power over

one’s life.

3. Strengthen Community Action: Community Participation53THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

Strategies for empowering the community include leadership training, learning

opportunities for health, and access to resources including material and

funding Empowerment helps people to identify their own needs and concerns, and gain

the power, skills and confidence to act upon them. It is a bottom-up strategy

which requires the health promoter to act as a facilitator and catalyst for

change.

4. Develop Personal Skills54THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

Skills which can promote an individual’s health include those pertaining to identifying, selecting and applying healthy options in daily life.

Health education is life-long, so that people can develop the relevant skills to meet the health challenges of all stages of life, and to be able to cope with chronic illness and disabilities.

Health education should be conducted in all settings.

4. Develop Personal Skills

55THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

Shift of emphasis from provision of curative services.

Health care system must be equitable and client-centered.

May necessitate reengineering and organizational change, especially in

the areas of professional education and training, management, recruitment

and deployment of health personnel, and planning, development and

delivery of services,

5. Reorient Health Services56THE FIVE MAJOR AREAS/STRATEGIES IN HEALTH PROMOTION (OTTAWA CHARTER)

57

Building a healthy public policy

Creating supportive

environments

Developing personal skills

Strengthening community

action

Reorientating health

services

IMPORTANT AREAS FOR CONSIDERATION IN HEALTH PROMOTION

Adelaide Recommendations on Healthy Public PolicySecond International Conference on Health Promotion, Adelaide, South Australia, 5-9 April 1988

The Conference strongly recommends that the World Health Organization continue the dynamic development of health promotion through the fivestrategies described in the Ottawa Charter. It urges the World Health Organization to expand this initiative throughout all its regions as an

integrated part of its work. Support for developing countries is at the heart of this process.

Healthy Public Policy

58

Sundsvall Statement on Supportive Environments for HealthThird International Conference on Health Promotion, Sundsvall, Sweden, 9-15 June 1991

The Sundsvall Conference has again demonstrated that the issues of health, environment and human development cannot be separated. Development must imply improvement in the quality of life and health while preserving the sustainability of the environment. Only worldwide action based on global partnership will ensure the future of our planet

Supportive environment for Health

59

Jakarta Declaration on Leading Health Promotion into the 21st CenturyThe Fourth International Conference on Health Promotion: New Players for a New Era - Leading Health Promotion into the 21st Century, Jakarta, Indonesia, 21-25 July 1997

The Jakarta Declaration included Five Priorities for Health Promotion in 21st Century

1. “Promote Social Responsibility for health”2. “Increase investments for health development”3. “Consolidate and expand partnerships for health”4. “Increase community capacity and empower the individual”5. “Secure an infrastructure for health promotion”

60

The participants endorsed the formation of a Global health promotion alliancePriorities for the alliance include:• Raising awareness of the changing determinants of health• Supporting the development of collaboration and networks for health development• Mobilizing resources for health promotion• Accumulating knowledge on best practice• Enabling shared learning• Promoting solidarity in action• Fostering transparency and public accountability in health promotion

61

Mexico Ministerial Statement for the Promotion of Health: From Ideas to ActionFifth Global Conference on Health Promotion, Health Promotion: Bridging the Equity Gap, Mexico City, 5-9 June 2000The attainment of the highest possible standard of health is a positive asset for the enjoyment of life and necessary for social and economic development and equity.8 Statements and 6 Actions where signed by 88 Countries world wide.

62

The ‘Bangkok Charter for Health Promotion in a globalized world’ It has been agreed to by participants at the 6th Global Conference on Health Promotion held in Thailand from 7-11 August, 2005

1. Make the promotion of health central to the global development agenda.2. Make the promotion of health a core responsibility for all of government.3. Make the promotion of health a key focus of communities and civil society.4. Make the promotion of health a requirement for good corporate practice.

63

Basic Strategies for Health Promotion

Advocate

Enable

Mediate

64

Advocate

Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioral and biological factors can all favor health or be harmful to it. Health promotion action aims at making these conditions favorable through advocacy for health.

65

Enable

Health promotion focuses on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. This must apply equally to women and men.

66

Mediate

The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned: by governments, by health and other social and economic sectors, by nongovernmental and voluntary organization, by local authorities, by industry and by the media. People in all walks of life are involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to mediate between differing interests in society for the pursuit of health.

Health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to take into account differing social, cultural and economic systems.

67

6 Major Elements

Better Health policy. Physical environment. Social environment. Community relationships. Personal health skills. Health services

68

Prerequisites for Health

The fundamental conditions and resources for health are:peace,shelter,education,food,income,a stable eco-system,sustainable resources,social justice, and equity.

69

HEALTH PROMOTION: WHERE DO WE START?

From disease/conditions. From issues eg. Safety, environment, tobacco control. From lifestyles. From settings eg. workplace

homeschoolsclinics

70

SETTINGS FOR HEALTH

This approach to health promotion arose from the Ottawa Charter:

“Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love”.

71

WHY SETTINGS?

Human health behaviour is determined by the physical and social forces which are present and interacting in any setting.

Involves the target population as a whole in the context of their everyday life and in their unique environment.

Holistic and comprehensive approach.

72

SETTINGS FOR HEALTH The Settings For Health approach in concerned with

creating health in our different settings.

Examples of Healthy Setting are: Healthy Cities Healthy Villages Healthy Islands Health Promoting Hospitals Health Promoting Schools

73

CONCLUSION The concept of health promotion is positive, dynamic and

empowering which makes it rhetorically useful and politically attractive.

By considering the recommended principles, subject areas, policy priorities and dilemmas it is hoped that future activities in the health promotion field can be planned, implemented and evaluated more successfully.

Further development work is clearly required and this will be an ongoing task of the WHO Regional Office for Europe.

74

ReferencesOnlinewww.who.int/topics/health_promotionwww.healthpromotionjournal.comwww.iuhpe.orgped.sagepub.comBooks1.A Text Book of Health Education (Philosophy and Principles) by Hari Bhakta Pradhan, Educational Resources for Health, Kathmandu, Nepal.2.Foundations and Principles of Health Education by Nicholas Galli, University of Illinois, Illinois3.Education For Health A Manual.. WHO4.Theory in a Nutshell : A practical guide to HP Theories…Don Nutbeam and Elizabeth Harris5.HP.. Bedworth

75

Thank youMail me please to get your contents

76