MODELS OF MODELS OF HEALTH PROMOTIONHEALTH PROMOTION

Objectives: You students will

• Understand the parameters required for health promotion model

• Be able to apply those parameters on models they may suggest for your own society

MODEL OF HEALTH PROMOTION 1: FOUR MODEL OF HEALTH PROMOTION 1: FOUR PARADIGMS OF HEALTH PROMOTION (CAPLAN PARADIGMS OF HEALTH PROMOTION (CAPLAN AND HOLLAND - 1990)AND HOLLAND - 1990)

RADICAL HUMANIST

• Holistic view of health

• De-professionalization

• Self-help networks

HUMANIST

• Holistic view of health

• Aims to improve understanding and development of self

• Client-led

RADICAL STRUCTURLIST

• Health reflects structural inequalities

• Need to challenge inequity and radically transform society.

TRADITIONAL

• Health = absence of disease

• Aim is to change behaviour

• Expert-led

Radical change

Subjective

Social regulation

Objective

Nature of knowledge

Nature of society

MODEL OF HEALTH PROMOTION 2: HEALTH MODEL OF HEALTH PROMOTION 2: HEALTH PROMOTION METHODS USING BEATTIE’S PROMOTION METHODS USING BEATTIE’S TYPOLOGY (BEATTIE – 1991)TYPOLOGY (BEATTIE – 1991)

Advice

Education

Behaviour change

Mass media campaign

Counselling

Education

Group work

Legislation

Policy making and implementation

Health surveillance

Lobbying

Action research

Skills sharing and training

Group work

Community development

MODE OF INTERVENTION

Individual

Negotiated

Collective

Focus of intervention

Authoritarian

MODEL OF HEALTH PROMOTION 3: A TYPOLOGY MODEL OF HEALTH PROMOTION 3: A TYPOLOGY OF HEALTH PROMOTION (FRENCH – 1990)OF HEALTH PROMOTION (FRENCH – 1990)

DISEASE MANAGEMENT

• Curative services

• Management services

• Caring servicesDISEASE PREVENTION

• Preventive services

• Medical services

• Behaviour change

HEALTH EDUCATION

• Agenda setting

• Empowerment and support

• InformationPOLITICS OF HEALTH

• Social action

•Policy development

• Economic and fiscal policy

MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE MODEL OF HEALTH PROMOTION (DOWNIE et alet al – – 1990) 1990)

Health education

PreventionHealth protection

1

2

3

4

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 lifeskills with young people.

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

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

MODEL OF HEALTH PROMOTION 5: THE MODEL OF HEALTH PROMOTION 5: THE CONTRIBUTION OF EDUCATION TO HEALTH CONTRIBUTION OF EDUCATION TO HEALTH PROMOTION (TONES PROMOTION (TONES et alet al – – 1990)1990)

Healthy public policy

Lobbying

Advocacy

Mediation

Public pressure

Healthy social and physical environment

Healthy promoting organisation

Professional education

Healthy services

HEALTH

Healthy choices

Agenda setting

Education for health

Critical consciousness raising

Empowered participating community

APPROACHES TO HEALTH PROMOTION

Approaches in Health Promotion: the example of healthy eating

Approach Aims MethodsWorker/clientrelationship

Medical To identify those at risk from disease.

Primary health care consultation.

e.g. measurement of body mass.

Expert-led.

Passive, conforming client.

Approaches in Health Promotion: the example of healthy eating

Approach Aims MethodsWorker/clientrelationship

Behavior change

To encourage individuals to take responsibility for their own health and choose healthier lifestyles.

Persuasion through one-to-one advice, information, mass campaigns, e.g. ‘Look After Your Heart’ dietary messages.

Expert-led.

Dependent client.

Victim blaming ideology.

Approaches in Health Promotion: the example of healthy eating

Approach Aims MethodsWorker/clientrelationship

Educational To increase knowledge and skills about healthy lifestyles.

Information.

Exploration of attitudes through small group work.

Development of skills, e.g. women’s health group.

May be expert led.

May also involve client negotiation of issues for discussion.

Approaches in Health Promotion: the example of healthy eating

Approach Aims MethodsWorker/clientrelationship

Empowerment To work with client or communities to meet their perceived needs.

Advocacy

Negotiation

Networking

Facilitation e.g. food co-op, fat women’s group.

Health promoter is facilitator, client becomes empowered.

Approach Aims MethodsWorker/clientrelationship

Social change To address inequalities in health based on class, race, gender, geography.

Development of organizational policy, e.g. hospital catering policy

Public health legislation, e.g. food labelling.

Fiscal controls, e.g. subsidy to farmers to produce lean meat.

Entails social regulation and is top-down.

Approaches in Health Promotion: the example of healthy eating

Religion and Health - 3

Figure 1: Pathways of ‘Islamic Health Theory’

Quran & Ahadith

Five Pillars of Islam

Elements of Faith

Islamic Jurisprudence

Salutogenic Mechanism

Sense of coherence

Predisposing &Enabling factors

Behavior

Healthy Lifestyle

Putting Islamic Concepts Into Practice for Health Promotion 1

Act

Plan

Do

Check

• Precede-proceed model.

• Intervention mapping.

• A five-stage model.

Putting Islamic Concepts Into Practice for Health Promotion 2

Putting Islamic Concepts Into Practice for Health Promotion 2.1

The PRECEDE-PROCEED Model by Green & Kreuter, 1999

Visit the website below for a figure of this model.

http://oc.nci.nih.gov/services/Theory_at_glance/PP_Part_3_cont.html#anchor248267

Intervention mapping.

Putting Islamic Concepts Into Practice for Health Promotion 2.2

STEP 1: Proximal program objective matricesSTEP 2: Theory –based methods and practical strategiesSTEP 3: Program planSTEP 4: Adoption and implementation planSTEP 5: Evaluation plan

A five-stage model (Bracht et al. 1999)

Putting Islamic Concepts Into Practice for Health Promotion 2.3

COMMUNITY

ORGANIZATIONSTAGES

1. Community analysis

2. Design - initiation

3. Implementation

4. Maintenance - consolidation

5. Dissemination - reassessment

1. Community analysis.

Putting Islamic Concepts Into Practice for Health Promotion 3.1

An illustration using the five-stage model (Bracht et al. 1999)

2. Design - initiation.

Putting Islamic Concepts Into Practice for Health Promotion 3.2

An illustration using the five-stage model (Bracht et al. 1999)

3. Implementation.

Putting Islamic Concepts Into Practice for Health Promotion 3.3

An illustration using the five-stage model (Bracht et al. 1999)

4. Maintenance - consolidation.

Putting Islamic Concepts Into Practice for Health Promotion 3.4

An illustration using the five-stage model (Bracht et al. 1999)

5. Dissemination - reassessment.

Putting Islamic Concepts Into Practice for Health Promotion 3.5

An illustration using the five-stage model (Bracht et al. 1999)

Promoting Healthy Behavior

Behavior and Global Health

• Physical good health eludes billions of people• Death and disease from preventable causes

remain high

• Behavior is a key factor in determining health

“Health is a state of complete physical, psychological, and social well-being and not simply the absence of disease or infirmity.” (World Health Organization, 1948)

Ten Leading Risk Factorsfor Preventable Disease

• Maternal and child underweight

• Unsafe sex• High blood pressure• Tobacco• Alcohol• Unsafe water, poor

sanitation, & hygiene

• High cholesterol• Indoor smoke from

solid fuels• Iron deficiency• High body mass index

or overweight

Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002), accessed online at www.who.int, on Nov. 15, 2004.

Whose Behavior is Responsible For…

• Maternal and child underweight• Smoking and alcohol abuse • Unsafe sex • Unsafe water and lack of adequate sanitation

Maternal and Child Underweight

• Individuals (may resist nutrition education)

• Communities (male preference norms)

• Policymakers (fail to address poverty)

• Health planners and health workers (do not include nutrition programs for the poor)

Smoking and Alcohol Abuse

• Individuals (choice)

• Communities (norms regarding smoking)

• Health policymakers

• Legislators & tax assessors

• Tobacco company executives

• Decision-makers in marketing companies

Unsafe Sex

• Individuals (abstinence, fidelity, condoms)

• Communities (norms regarding male dominance

and multiple partners)

• Poverty (transactional sex for poor women)

• Health policymakers and health workers

(effective AIDS prevention programs)

Unsafe Water and Lack of Adequate Sanitation

• Individuals (where they fetch water, boiling

water, washing hands)

• Communities (fatalism regarding diarrheal

diseases, community latrines)

• Governments (ignore or underfund safe

water and sanitation needs)

Risky behaviors translate to diseases

Global Causes of Death

31%

9%

60%

Noncommunicable diseases

Communicable diseases,

maternal and perinatal

conditions, and nutritional

deficiencies

Injuries

Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).

Behavior change reduces risky behaviors

Health Promotion Means Changing Behavior at Multiple Levels

A Individual: knowledge, attitudes, beliefs, personality

B Interpersonal: family, friends, peers C Community: social networks, standards,

norms D Institutional: rules, policies, informal

structuresE Public Policy: local policies related to

healthy practicesSource: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at http://cancer.gov.

A: Individual-Oriented Models

• Individual most basic unit of health promotion

• Individual-level models components of broader-level theories and approaches

• Models– Stages of Change Model– Health Belief Model

Stages of Change Model

• Changing one’s behavior is a process, not an event

• Individuals at different levels of change

• Gear interventions to level of change

Source: James O. Prochaska et al., “In Search of How People Change: Application to Addictive Behaviors,” American Psychologist 47, no. 9 (1992): 1102-14.

Stages of Change Model (cont.)

Precontemplation

Action Decision

Maintenance Contemplation

Health Belief Model

• Perceived susceptibility and severity of ill health

• Perceived benefits and barriers to action

• Cues to action

• Self-efficacy

Source: Irwin M. Rosenstock et al., “Social Learning Theory and the Health Belief Model,” Health Education Quarterly 15, no. 2 (1988): 175-85.

B: Interpersonal Level:Social Learning Theory

• Interaction of individual factors, social environment, and experience

• Reciprocal dynamic

• Observational learning

• Capability of performing desired behavior

• Perception of self-efficacy

Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).

Interpersonal Level:Social Learning Theory (cont.)

• Three strategies for increasing self-efficacy– Setting small, incremental goals– Behavioral contracting: specifying goals and

rewards– Self-monitoring: feedback can reinforce

determination to change (keep a diary)

• Positive reinforcement: encouragement helps

Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).

C: Community-Level Models

• Analyze how social systems function

• Mobilize communities, organizations, and policymakers

• Use sound conceptual frameworks– Community Mobilization– Organizational Change– Diffusion of Innovations Theory

Community Mobilization

• Encompasses wider social and political contexts

• Community members assess health risks, take action

• Encourages empowerment, building on cultural strengths and involving disenfranchised groups

Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire, Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).

Organizational ChangeOrganizational Stage

TheoryDefine problem

Identify solutions

Initiate action

Allocate resources

Implement

Institutionalize

Organizational Development Theory

Worker behavior and motivation

Organizational structures

Diffusion of Innovations Theory

• How new ideas, products, and behaviors become norms

• All levels: individual, interpersonal, community, and organizational

• Success determined by: nature of innovation, communication channels, adoption time, social system

Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).

Diffusion of Innovations (cont.)

Nature of innovation

• Relative advantage over what is being replaced

• Compatible with values of intended users

• Easy to use

• Opportunity to try innovation

• Tangible benefits

Diffusion of Innovations (cont.)

Communication channels

• Mass media (enhanced by listening groups, call-in opportunities, and face-to-face approaches)

• Peers

• Respected leaders

Diffusion of Innovations (cont.)

Adoption time

• Awareness Intention Adoption Change

• Gradual

• Movement through groups– Pioneers– Early adopters– Masses

Diffusion of Innovations (cont.)

Social system:

• Identify influential networks to diffuse innovation: health systems, schools, religious and political groups, social clubs, unions, and informal associations

• Identify opinion leaders, peers, and targeted media channels to diffuse innovations

Health Promotion

Health Promotion Tools

• Mass media

• Social marketing

• Community mobilization

• Health education

• Client-provider interactions

• Policy communication

Source: Robert Hornik and Emile McAnany, “Mass Media and Fertility Change,” in Diffusion Processes and Fertility Transition: Selected Perspectives, ed. John Casterline (Washington, DC: National Academies Press, 2001): 208-39.

Behavior Change Successes

• Reducing malnutrition (micronutrient initiatives)

• Preventing malaria (insecticide-treated bednets)

• Helping children survive (breastfeeding)

• Improving maternal health (safe motherhood movement, emergency obstetric care)

• Making family planning a norm (worldwide efforts)

• Combating HIV/AIDS (Uganda program)

Combating HIV/AIDS in Uganda• Political support, multisectoral response• Decentralized behavior change campaigns• Focus on women and youth, stigma and

discrimination• Mobilization of religious leaders• Confidential voluntary counseling and

testing• Social marketing of condoms• Control and prevention of STIs

Source: Edward C. Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries (Westport, CT: Praeger Publishers, 2003).

Health Promotion: Lessons Learned

• Research underlying causes

• Address contextual factors

• Identify and reach key actors at every level

• Involve stakeholders throughout process

• Use sound behavioral theories

• Monitor and evaluate

Conclusion

• Improving global health requires behavior change at every level—individuals, families, communities, organizations, and policymaking bodies

• Evidence-based behavioral theories and successful behavior-change case histories point the way

• Next step: political will and sufficient resources

For More Information

Elaine M. Murphy, “Promoting Healthy Behavior,” Health Bulletin 2 (Washington, DC: Population Reference Bureau, 2005).

Available online at www.prb.org

Objectives: You Students will

• Understand the parameters required for health promotion model.

• Be able to apply those parameters on models they may suggest for their own society.