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HEALTH PROMOTION:HEALTH PROMOTION:Models and ApproachesModels and Approaches

JOSEF TRAPANIJOSEF TRAPANI

EN EN –– SN Conversion CourseSN Conversion Course

October 2007October 2007

OctOct--0707EN EN --SN Conversion Course SN Conversion Course

J. TrapaniJ. Trapani 22

TOPTOP--DOWN VS. BOTTOMDOWN VS. BOTTOM--UPUP

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

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



FIVE MAIN APPROACHESFIVE MAIN APPROACHES

1.1. The Medical or Preventive ApproachThe Medical or Preventive Approach

2.2. The Behaviour Change or Lifestyles The Behaviour Change or Lifestyles ApproachApproach

3.3. The Educational ApproachThe Educational Approach

4.4. The Empowerment or ClientThe Empowerment or Client--Centred Centred ApproachApproach

5.5. The Social Change or Radical ApproachThe Social Change or Radical Approach

THE MEDICAL THE MEDICAL OR OR

PREVENTIVE PREVENTIVE APPROACHAPPROACH



THE MEDICAL APPROACHTHE MEDICAL APPROACH

•• AimAim::–– Reduce morbidity and premature mortalityReduce morbidity and premature mortality

–– Target whole populations or high risk Target whole populations or high risk groupsgroups

•• HP ActivityHP Activity: Promotion of : Promotion of medical intervention to medical intervention to prevent or ameliorate illprevent or ameliorate ill--healthhealth



MEDICAL APPROACHMEDICAL APPROACH

1.1. PrimaryPrimary preventionprevention –– prevention of prevention of onset of disease, e.g. immunisation; onset of disease, e.g. immunisation; encouraging non smokingencouraging non smoking

2.2. Secondary preventionSecondary prevention –– preventing preventing progression of disease, e.g. Screeningprogression of disease, e.g. Screening

3.3. Tertiary preventionTertiary prevention –– reducing further reducing further disability and suffering in those already disability and suffering in those already ill, e.g. Rehabilitation, patient education, ill, e.g. Rehabilitation, patient education, palliative carepalliative care



POPULARITY OF THE MEDICAL APPROACHPOPULARITY OF THE MEDICAL APPROACH

•• Uses Uses scientific methodsscientific methods, e.g. epidemiology, e.g. epidemiology

•• Prevention and early Prevention and early

detection of disease detection of disease

is is cheapercheaper than treatmentthan treatment

•• TopTop--down approachdown approach, i.e. led by experts ... , i.e. led by experts ... reinforces authority of health professionals who reinforces authority of health professionals who are viewed as having necessary knowledge to are viewed as having necessary knowledge to achieve resultsachieve results

•• Highly Highly successful examplessuccessful examples in the past, e.g. in the past, e.g. eradication of smallpoxeradication of smallpox



DISADVANTAGESDISADVANTAGES

•• Focuses on the absence of disease rather than Focuses on the absence of disease rather than on promoting positive healthon promoting positive health

•• Based on a medical definition of healthBased on a medical definition of health

•• Ignores the social and enviromental dimensions Ignores the social and enviromental dimensions of healthof health

•• Encourages dependency on medical knowledge Encourages dependency on medical knowledge and compliance with treatmentsand compliance with treatments

•• Removes health decisions from the people Removes health decisions from the people concerned (paternalistic approach)concerned (paternalistic approach)



REQUIREMENTS FOR REQUIREMENTS FOR MEDICAL APPROACHMEDICAL APPROACH

•• Preventive procedures need to be based Preventive procedures need to be based on a sound rationale derived from on a sound rationale derived from epidemiological evidenceepidemiological evidence

•• Relies on having an infrastructure capable Relies on having an infrastructure capable of delivering screening or an immunisation of delivering screening or an immunisation programme, e.g. Trained personnel, programme, e.g. Trained personnel, equipment and laboratory facilities, record equipment and laboratory facilities, record keeping facilities, effective and safe keeping facilities, effective and safe vaccinevaccine



EVALUATION OF MEDICAL EVALUATION OF MEDICAL APPROACHAPPROACH

•• Short Term EffectsShort Term Effects–– Increase in percentage of target population Increase in percentage of target population being screened or immunisedbeing screened or immunised

•• Long Term EffectsLong Term Effects–– Reduction in disease rates and associated Reduction in disease rates and associated mortalitymortality

THE THE BEHAVIOURAL BEHAVIOURAL

CHANGE CHANGE (LIFESTYLES) (LIFESTYLES) APPROACHAPPROACH



AIMS AND ASSUMPTIONSAIMS AND ASSUMPTIONS

•• Encourages individuals to adopt healthy Encourages individuals to adopt healthy behaviours which improve healthbehaviours which improve health

•• Views health as a property of individualsViews health as a property of individuals

•• People can make real improvements to their People can make real improvements to their health by choosing to change lifestylehealth by choosing to change lifestyle

•• It is peopleIt is people’’s responsibility to take action to s responsibility to take action to look after themselveslook after themselves

•• Involves a change in attitude Involves a change in attitude followed by a change in behaviourfollowed by a change in behaviour



LIMITATIONSLIMITATIONS

•• Health related decisions are very complex Health related decisions are very complex

•• Depends on personDepends on person’’s readiness to take s readiness to take actionaction

•• Complex relationship between individual Complex relationship between individual behaviour and social and environmental behaviour and social and environmental factorsfactors

•• Behaviour may be a response to a Behaviour may be a response to a personspersons’’ living conditions which may be living conditions which may be beyond individual control (e.g. Poverty, beyond individual control (e.g. Poverty, unemployment)unemployment)



METHODSMETHODS

•• Campaigns to persuade people e.g.Campaigns to persuade people e.g.

–– Not to smokeNot to smoke

–– To drink To drink ‘‘sensiblysensibly’’

–– To adopt a healthy dietTo adopt a healthy diet

–– To undertake regular exercise, To undertake regular exercise, etc.etc.

•• Targeted towards individualsTargeted towards individuals

•• May use massMay use mass--media to reach themmedia to reach them



EVALUATIONEVALUATION

•• Theoretically SimpleTheoretically Simple

–– Ask: Ask: ““Has the health behaviour changed after Has the health behaviour changed after the intervention?the intervention?””

HOWEVERHOWEVER

•• Change may become apparent only after a Change may become apparent only after a long periodlong period

•• Difficult to determine whether behaviour Difficult to determine whether behaviour change was due to HP interventionchange was due to HP intervention

THE THE EDUCATIONAL EDUCATIONAL APPROACHAPPROACH



AIMS AND VALUESAIMS AND VALUES

•• To enable people to make an informed To enable people to make an informed choice about their health behaviour bychoice about their health behaviour by–– providing knowledge and information ANDproviding knowledge and information AND

–– developing the necessary skills developing the necessary skills

•• Does NOT try to persuade or motivate Does NOT try to persuade or motivate change in one directionchange in one direction

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



ASSUMPTIONS AND LIMITATIONSASSUMPTIONS AND LIMITATIONS

ASSUMES THAT:ASSUMES THAT:

•• Increase in knowledge Increase in knowledge �� change in change in attitudes attitudes �� behaviour changebehaviour change

BUTBUT

•• Voluntary behaviour change may be Voluntary behaviour change may be restricted by social and economic factorsrestricted by social and economic factors

•• Health related decisions are very complexHealth related decisions are very complex



ASPECTS OF LEARNINGASPECTS OF LEARNING

1.1. Cognitive Aspect Cognitive Aspect -- Provision of Provision of informationinformationabout causes and effects of healthabout causes and effects of health--related related behavioursbehaviours•• Provision of leaflets/bookletsProvision of leaflets/booklets

•• Visual displaysVisual displays

•• OneOne--toto--one adviceone advice

2.2. Affective Aspect Affective Aspect -- Provision of Provision of opportunities for clients to share and explore opportunities for clients to share and explore their their attidutes and feelingsattidutes and feelings::•• OneOne--toto--one counsellingone counselling

•• Group discussionsGroup discussions



ASPECTS OF LEARNINGASPECTS OF LEARNING

3.3. Behavioural Aspect Behavioural Aspect -- Helping clients Helping clients develop decisiondevelop decision--making making skillsskillsrequired for healthy livingrequired for healthy living•• Exploring Real life situationsExploring Real life situations

•• Role Play Role Play

–– Examples: reaction when offered a drink / Examples: reaction when offered a drink / cigarette / drugs; negotiating contraception cigarette / drugs; negotiating contraception useuse




•• Various methods of health education Various methods of health education shown to be effective in improving shown to be effective in improving knowldegeknowldege

HOWEVERHOWEVER

•• Knowledge is rarely translated into Knowledge is rarely translated into behaviourbehaviour

THE THE EMPOWERMENT EMPOWERMENT

OR CLIENT OR CLIENT CENTRED CENTRED APPROACHAPPROACH



VALUES OF EMPOWERMENTVALUES OF EMPOWERMENT

•• Helps people identify their own concerns Helps people identify their own concerns and gain the skills and confidence and gain the skills and confidence necessary to act upon themnecessary to act upon them

•• This is the only approach to use a This is the only approach to use a ‘‘bottombottom--upup’’ (rather than (rather than ‘‘toptop--downdown’’) ) approachapproach

•• Health promoter plays the role of a Health promoter plays the role of a facilitatorfacilitator rather than that of an expertrather than that of an expert

•• Initiates the process but then withdraws Initiates the process but then withdraws from the situationfrom the situation



•• Clients are seen as equal Clients are seen as equal

and have the right to set and have the right to set

their own agendatheir own agenda

•• In line with health promotion as defined in the In line with health promotion as defined in the Ottawa Charter (WHO,1986): Ottawa Charter (WHO,1986): ““enabling people enabling people to gain control over their livesto gain control over their lives””

•• May involve May involve empowerment empowerment of both individuals of both individuals and entire communitiesand entire communities



CONDITIONS FOR EMPOWERMENTCONDITIONS FOR EMPOWERMENT

•• For people to be empowered they need For people to be empowered they need to:to:

1.1. Recognise and understand their Recognise and understand their powerlessnesspowerlessness

2.2. Feel strongly enough about their situation to Feel strongly enough about their situation to want to change itwant to change it

3.3. Feel capable of changing the situation by Feel capable of changing the situation by having information, support and life skillshaving information, support and life skills

(Naidoo and Wills, 2000: p.98)(Naidoo and Wills, 2000: p.98)



EMPOWERMENT IN PRACTICEEMPOWERMENT IN PRACTICE

•• Examples:Examples:

–– Nurses working with patients Nurses working with patients to develop a care planto develop a care plan

–– Teachers working with pupils to Teachers working with pupils to raise their selfraise their self--esteemesteem

•• Health promoter may feel unomfortable in Health promoter may feel unomfortable in relenquishing his expert rolerelenquishing his expert role




•• Usually empowerment is a long term Usually empowerment is a long term processprocess

•• Difficult to conclude that changes are due Difficult to conclude that changes are due to the intervention rather than some other to the intervention rather than some other factorfactor

•• Results are vague and hard to quantify Results are vague and hard to quantify compared with those of other approachescompared with those of other approaches

THE SOCIETAL THE SOCIETAL CHANGE OR CHANGE OR RADICAL RADICAL APPROACHAPPROACH



SOCIETAL CHANGE APPROACHSOCIETAL CHANGE APPROACH

•• Radical approach which aims to change Radical approach which aims to change society not individual behavioursociety not individual behaviour

•• Aims at producing a physical and social Aims at producing a physical and social environmentenvironment

•• Healthy choice to become the easier Healthy choice to become the easier choice in terms of cost, availability and choice in terms of cost, availability and accessibilityaccessibility

•• Targeted towards groups and populationsTargeted towards groups and populations



SOCIETAL CHANGE APPROACHSOCIETAL CHANGE APPROACH

•• Requires political support from the Requires political support from the highest level, e.g. through highest level, e.g. through legislationlegislation

•• Needs support of the publicNeeds support of the public

•• Public needs to be informed Public needs to be informed of its importanceof its importance

•• Health promoter involved in Health promoter involved in lobbying, policy planning, lobbying, policy planning, negotiating and negotiating and implementationimplementation




•• Outcomes may include Outcomes may include

–– changes in laws or regulations changes in laws or regulations

•• e.g. Smoking bans, food labelling, applying taxes / e.g. Smoking bans, food labelling, applying taxes / subsidies on certain types of foodssubsidies on certain types of foods

–– Improvement in the profile of health issues on Improvement in the profile of health issues on common agendascommon agendas

•• May be difficult to prove link with HP May be difficult to prove link with HP interventions as change is usually a interventions as change is usually a lengthy processlengthy process

THE FIVE APPROACHES: THE FIVE APPROACHES: EXAMPLES RELATED TO SMOKINGEXAMPLES RELATED TO SMOKING

Based on Based on

Ewles and Simnet (1992: 36)Ewles and Simnet (1992: 36)



THE MEDICAL APPROACHTHE MEDICAL APPROACH

•• AIMAIM: Free from lung disease, heart : Free from lung disease, heart disease and other smoking related disease and other smoking related disordersdisorders

•• ACTIVITYACTIVITY: Encourage people to seek early : Encourage people to seek early detection and treatment of smoking detection and treatment of smoking related disordersrelated disorders



BEHAVIOUR CHANGEBEHAVIOUR CHANGE

•• AIMAIM: Behaviour changes : Behaviour changes from smoking to not from smoking to not smokingsmoking

•• ACTIVITYACTIVITY: Persuasive : Persuasive education to education to

–– prevent nonprevent non--smokers from smokers from starting ANDstarting AND

–– persuade smokers to stoppersuade smokers to stop



EDUCATIONAL APPROACHEDUCATIONAL APPROACH•• AIMAIM: Clients understand effects of smoking on : Clients understand effects of smoking on health and will make a decision whether to health and will make a decision whether to smoke or not and act on their decisionsmoke or not and act on their decision

•• ACTIVITYACTIVITY::

–– Giving information to clients Giving information to clients about effects of smokingabout effects of smoking

–– Helping them explore their Helping them explore their values and attitudes and come values and attitudes and come to a decisionto a decision

–– Helping them learn how to stop Helping them learn how to stop smoking if they want tosmoking if they want to



THE CLIENT CENTRED APPROACHTHE CLIENT CENTRED APPROACH

•• AntiAnti--smoking issue is smoking issue is considered only if clients considered only if clients identify it as a concernidentify it as a concern

•• Clients identify what, if Clients identify what, if anything, they want to anything, they want to know and do about itknow and do about it



SOCIETAL CHANGESOCIETAL CHANGE

•• AIMAIM–– Make smoking socially unacceptable Make smoking socially unacceptable so it is easier not to smoke than to so it is easier not to smoke than to smokesmoke

•• ACTIVITYACTIVITY–– No smoking policy in all public placesNo smoking policy in all public places–– Cigarette sales less accessibleCigarette sales less accessible–– Promotion of nonPromotion of non--smoking as a social normsmoking as a social norm–– Limiting and challenging tobacco advertisments and Limiting and challenging tobacco advertisments and sports sponsorshipssports sponsorships

TANNAHILLTANNAHILL’’S MODEL (Downie S MODEL (Downie et alet al., 1996)., 1996)

Health

Education

Prevention

5

3

2

4

7

1

Health Protection

6

Positive Health Education e.g. Lifeskills for youths

Preventive Services e.g. Immunisation,

Sceening

Positive Health Protection e.g. workplace

smoking policy

Preventive health education, e.g.

Smoking cessation advice and information

Health education aimed at positive health protection e.g. Lobbying for a ban on tobacco

advertising

Preventive health protection e.g. Flouridation of

water

Health education for preventive health

protection e.g. Lobbying for seat belt legislation



REFERENCES AND FURTHER REFERENCES AND FURTHER READINGREADING

•• Ewles L., Simnett I. (1999) Ewles L., Simnett I. (1999) Promoting health: A practical Promoting health: A practical guideguide, 4th ed. Edinburgh: Balli, 4th ed. Edinburgh: Ballièère Tindallre Tindall

•• Naidoo J., Wills J. (2000) Naidoo J., Wills J. (2000) Health promotion: Foundations Health promotion: Foundations for practicefor practice, 2nd ed. Edinburgh: Balli, 2nd ed. Edinburgh: Ballièère Tindallre Tindall

•• Downie R.S., Tannahill C., Tannahill A. (1996) Downie R.S., Tannahill C., Tannahill A. (1996) Health Health Promotion: models and valuesPromotion: models and values. Oxford: Oxford Medical . Oxford: Oxford Medical PublicationsPublications

•• Tones K., Tilford S. (1994) Tones K., Tilford S. (1994) Health Education: Health Education: effectiveness, efficiency and equityeffectiveness, efficiency and equity, 2nd ed. London: , 2nd ed. London: Chapman & HallChapman & Hall

•• Kemm J., Close A. (1995) Health promotion: theories Kemm J., Close A. (1995) Health promotion: theories and approaches. London: Macmillanand approaches. London: Macmillan

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