Principles of Dr Celine Murrin

Health Promotion School of Public Health, Physiotherapy and

Sport Science
Lecture outline

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

• Recognise different approaches to improving health.
• Understand the determinants of health.
• Recognise the scope of health promotion.
• Consider different health promotion strategies to different
contexts.

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What is Health Promotion?

Can you share an example of Health Promotion?

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 Public Health changes in ‘Modern’ times – Western World

Pre-World wars 1950s -1960s 1960s – Mid 80s Mid 80s – 2000

Chronic disease. Post-war prosperity.

Infectious Major Changes to lifestyle.
disease developments in Risk of chronic
Sanitation clinical medicine. disease. Poor Diet
Antibiotics Chronic disease Epidemiological Increased Smoking
Vaccines aetiology. methods – Increase Alcohol
Undernutrition Reduced Physical
Growth in treatment trends/patterns.
. Activity
– demand for Prevention to control
hospitals. costs.
Increase in health Individual behaviour.
Adapted from ‘New Public budgets. Educate the public.
Health’, Baum (1998) OUP. . 4
Approaches to health

Treatment phase
Medical Approach
Health Concept Biomedical; absence of
disease or disability
Health Disease categories,
determinant physiological risk factors
(e.g. hypertension)

Principal strategy Surgery, drugs, therapy,

illness care, medically
managed behavioural
change
Programme Professionally managed
development

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Approaches to health
Treatment Prevention phase.
Medical Approach Behavioral Approach
Health Concept Biomedical; absence of Individualized; physical- functional
disease or disability ability, physical wellbeing
Health Disease categories, Behavioural risk factors (e.g. unsafe sex)
determinant physiological risk factors
(e.g. hypertension)

Principal Surgery, drugs, therapy, Advocacy for healthy lifestyle choices

strategy illness care, medically
managed behavioural
change
Programme Professionally managed Negotiated with communities and
development professionals

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How did they try to change health behaviour in
1960s-1990s?

Health Education Approach

• Widespread public health education campaigns
(UK and US)
• Principle: If we increase awareness of risk to health
by engaging in these behaviours then people will
‘rationally’ change their behaviour.
• Doesn’t work as a standalone measure. Why?
Health Education for prevention
Why? Changing behaviour is complicated
Theories from behavioural psychology
 What determines Health behaviour and health
outcomes?
The Dahlgren and Whitehead model of the main determinants of health

Social and economic disadvantage

➔ damaging health behaviour
➔ difficulty in adopting new healthier behaviour.

This reinforces the importance of adopting a

person-centred approach to health
promotion ensuring that all factors, including
social influences of health and health
behaviours are considered
Alma Ata declaration 1978
Conference on Primary Health Care, Alma Ata.
expressing 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
• Health For all – a human right
• Primary Health Care key to realising right to health
• Intersectoral co-operation - Requires the action of other social and economic sectors not just health
sector.
• Community participation – health should be universally accessible to people through their full
participation.
• Equity – major inequities between developed and developing world and within populations.

Moving away from medical individualised model to population centred approach to health.

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The salutogenic paradigm (Antonovsky, 1990)
Question Pathogenic paradigm Salutogenic paradigm
How are people classified in Dichotomous classification: People are classified as As a continuum: Total health and total illness are the extreme poles.
terms of health status? either healthy or sick Humans are all partly healthy and partly sick
What is to be understood Focus of attention is on the scientific diagnosis of Focus of attention is on the assessment of the overall state of the
and treated? the specific disease of the patient health/illness of a person
Focus on the total story of a person which can explain location on the
Focus on the risk factors for a particular disease
continuum of health and disease, including salutary, health promoting
being considered
What are the important resources
etiological factors?

Starting point: disease or problem

Starting point: health potential
A stressor is conceptualized as somewhat unusual
and pathogenic A stressor is conceptualized as ubiquitous (inherent in human existence)
and open ended in consequences. A stressor such as divorce might, for
How are stressors example, turn out to have positive effects for someone’s wellbeing
conceptualized? (Chain: stressor-stress-disease)

Humans are flawed and subject to entropy

Disease or infirmity as an anomaly
By starting “a war against disease” By strengthening coping resources
How is suffering to be
treated?
React to signs, symptoms and indications of disease Create conditions of physical, mental and social well-being 13
Origins of Health Promotion
The Ottawa Charter for Health Promotion was developed at the First International Conference on
Health Promotion in 1986

First definition of Health Promotion:

Health promotion is the process of enabling people to increase control over, and to improve,
their health.

To reach a state of complete physical, mental and social 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, therefore, seen as a resource for everyday life, not the objective of living.
Health is a positive concept emphasizing social and personal resources, as well as physical capacities.
Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy
life-styles to well-being.

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Origins of Health Promotion
To reach a state of complete physical, Health promotion represents a
mental and social well-being, an comprehensive social and political
individual or group must be able to
process, it not only embraces actions
identify and to realize aspirations, to
satisfy needs, and to change or cope directed at strengthening the skills and
with the environment. Health is, capabilities of individuals, but also
therefore, seen as a resource for action directed towards changing
everyday life, not the objective of social, environmental and economic
living. Health is a positive concept
emphasizing social and personal conditions so as to alleviate their
resources, as well as physical impact on public and individual health
capacities. Therefore, health promotion
is not just the responsibility of the
health sector, but goes beyond
healthy life-styles to well-being.

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 Public Health changes in ‘Modern’ times – Western World

Pre-World wars 1950s -1960s 1960s – Mid 80s Mid 80s – today
Emergence of Health Promotion.

Chronic disease. Post-war prosperity. Individual & society.

Infectious Major Changes to lifestyle. Education & policy.
disease developments in Risk of chronic Empowerment.
Sanitation clinical medicine. disease. Public participation.
Antibiotics Chronic disease Epidemiological Settings approach to
Vaccines aetiology. methods – health.
Undernutrition Growth in treatment trends/patterns. Distinction between
. – demand for Prevention to control health and disease.
hospitals. costs. Distinction between
Increase in health Individual behaviour. prevention & promotion.
Adapted from ‘New Public budgets. Educate the public.
Health’, Baum (1998) OUP. . 16
Public Health changes in ‘Modern’ times – Western World

Pre-World wars 1950s -1960s 1960s – Mid 80s Mid 80s – today

Treatment phase

Prevention phase.
All continue to be
essential for health
Promotion
phase

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Approaches to health
Treatment Prevention Promotion
Medical Approach Behavioral Approach Socioecological Approach
Health Biomedical; absence of Individualized; physical- Positive state connectedness; ability to do
Concept disease or disability functional ability, physical things that are important or have
wellbeing meaning; psychological well- being

Health Disease categories, Behavioural risk factors Psychological risk factors (e.g. isolation)
determin physiological risk factors (e.g. (e.g. unsafe sex) and socioenvironmental risk conditions
ant hypertension) (e.g. poverty)

Principal Surgery, drugs, therapy, Advocacy for healthy Personal empowerment, small group
strategy illness care, medically lifestyle choices development, community organization,
managed behavioural change coalition advocacy, political action

Program Professionally managed Negotiated with Managed by community in critical

me communities and dialogue with supporting professionals
develop professionals and agencies
ment
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What is health promotion?

Health Promotion can be considered as:

• An academic discipline
• A profession
• An ideology – collection of beliefs and values

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Health Promotion Strategies
Complexity of socio-ecological determinants of health highlights importance
of delivering interventions with a mix of strategies across the health
promotion action areas.

Levels of intervention are consistent with the socio-ecological approach:

➢systems interventions target policy context/physical environment

determinants
➢community interventions address social and cultural determinants
➢individual interventions consider intrapersonal determinants of a health
problem.
Guided by Health Promotion Frameworks

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Health Promotion Framework
The Ottawa Charter provides 5 key action areas that are widely used and are considered
central to effective health promotion practice

• Building healthy public policy

• Creating supportive environment
• Strengthening community action
• Developing personal skills
• Re-orientating health services
https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference/actions

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Health Promotion Action Areas

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Health Promotion

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Health Promotion
Key facets of a health promoting approach
• Health is not just a biological or medical or issue
• Ecological orientation; systems approach
• Multi-sectoral responsibility
• Empowerment:
• participation at its core.
• Relies on what resources or ‘assets’ people already have
• People realise their own power or capacity to change
• Empowering people then facilitates real opportunities for choice.
• Settings approach:
• Develop environment that provides opportunity
• Involves education and healthy public policy
• Grounded in equity and social justice
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Health Promotion Settings Approach
•three dimensional matrix of options
Target
➢ Target group Group
➢ Settings
➢ Strategy selection Strategy Setting

•Settings offer opportunities for comprehensive

interventions which include both health behaviour change
and environmental change
➢ Schools
➢ Workplaces
➢ Homes
➢ Hospitals/Acute settings
➢ Communities
➢ Cities

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Health Promotion Approach
Key approaches for Health Promotion which are needed and applied to all action areas

• Enable – people to achieve their fullest health potential.

• Advocate – HP involves lobbying for change in the determinants of
health.
• Mediate –interagency, multisectoral collaborations; government,
industry, media; individuals, families, communities – differing interests
which demand co-ordinated action.

Based on the principle of collective responsibility for health

“ with people not for people”

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Enabling and empowerment
• Individuals and communities directly participate in the planning and
implementation of health promotion activities.
• Concept of ‘enabling’ also refers to the more general process of changing the
social, economic, and environmental conditions that made it difficult for
people to become empowered.
• All aspects of health promotion must integrate the fundamental perspective of
participation.
• (Disadvantaged people are assumed to be too ignorant or incapable of participating
and thus have solutions imposed on them)

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Advocacy

▪ Health professionals have a major responsibility to act as advocates for

health at all levels in society.
Approaches
▪ Mass media and multi-media
▪ Direct political lobbying
▪ Community mobilization e.g. coalitions of interest around defined issues
(think of settings – communities; clinics; hospital; school; workplace)

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Mediation
▪ Different interests (personal, social, economic) of individuals and
communities and different sectors (public and private) are reconciled in
ways that promote and protect health.
▪ Must result in sustainable change – not a sticking plaster/temporary fix.
▪ Risk of reinforcing the ‘powerful’ if there is not genuine mediation. Those
who hold the power may have nothing personal to gain.

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Health Promotion strategies
Following Selection of target group and setting, a number of strategies can be used in a
health promotion intervention

Systems Strategies: Changing public policy –national/regional/local/organisational policy

Systems Strategies: Environmental change –
physical/social/organisational
Community interventions: Community
mobilisation and development
Individual and interpersonal strategies:
Education, behaviour change, skill
development
Interpersonal and Systems strategies: Social
marketing

CDC. Colorectal Cancer Control Program: Adapted SEM approach to Health Promotion.
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Health Promotion strategies
How to influence Policy?

Advising – policy Advocacy

communication Media advocacy
Research and analysis Coalition building
briefings, reports Public opinion
Agenda setting
Use of scientific evidence

Lobbying
Timed to influence: Activism
Legislative actions Peaceful protests
Policy decisions Civil disobedience
Face-to-face meetings

Cooperation v. confrontation

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Health Promotion strategies
Influencing policy

PROBLEMS

POLICIES

POLITICS

Alignment of problems, policies

and politics allows health
to come through
Alignment of problems, policies and politics in creating “windows of opportunity”

Windows of opportunity when coupling of three streams occurs: problems,

policy (technically feasible and sustainable solutions) and politics (commitment)
Health Promotion strategies
Strategic policy communication
Direct policy communication - you want the Policy makers – short terms in office; political agenda
policy/decision makers to take action →evidence needs to be readily available → evidence
brief
e.g. Create new laws or regulations; Prevent
current laws or regulations from being Main steps.
threatened or discontinued; Enforce existing laws 1. State what you want to accomplish
and regulations; Direct more funding to 2. Decide who you are trying to reach
programmes or services; Raise taxes on products; 3. Research and craft the message
Change practices that are regulated by 4. Choose the ‘spokesperson’
government agencies. 5. Deliver the message
6. Evaluate your progress.
Health Promotion strategies
Strategic policy communication
Advocacy
Working with other people and organisations to Purpose is to persuade or motivate to support changes
make a difference in legislation, increase funding, increased enforcement
or regulation.
Putting a problem on the agenda, providing a
solution to that problem and building support to Policy or decision makers may be the primary audience.
act on both the problem and solution.
Can also consider other stakeholders – e.g. aligned
Can involve many specific, short-term activities organisations, selected members of the public or
to reach a long-term vision of change. anyone engaged with the issue without the law making
ability
Consists of different strategies aimed at
influencing decision-making at the
organisational, local, provincial, national and
international levels.
 Health Promotion strategies
Strategic policy communication
Advocacy Advocacy messages
6 Stages of advocacy A concise and persuasive statement about aim – what you want to achieve ,
why and how. What action do you want the audience to take.
‘one-minute message’
• Statement + evidence+ example + call for action.
• Command attention
• Deliver consistent message to an audience through multiple channels over a
long period of time.
• Credible source for the message and the messenger.
• Use a language the audience will understand.
• Positive language
Advocacy message formats
Formal or informal face-to-face meetings; Informal conversations at social,
religious, political gatherings; Letters; Briefing meetings; Programme site visits;
Factsheets, pamphlets, brochures; Graphics, illustrations; Videos, PPT;
Newspaper articles or advertisements.
 Health Promotion strategies
Media advocacy
Media advocacy by stakeholders could result in the recognition of an issue as a problem, create
awareness of possible solutions and generate wide scale political commitment:

• Broadcast media/main stream media

• Social media
Health Promotion strategies
Social Marketing
Included in behaviour change approaches
The adaptation of commercial marketing techniques to achieve specific behavioural goals for a
social good.
“A social change campaign is an organized effort conducted by one group (the change agent)
which attempts to persuade others (the target adopters) to accept, modify, or abandon certain
ideas, attitudes, practices or behaviour.” --Kotler, Roberto, &
Lee, 2002

• Consumer-oriented approach, but starts where people are now (not where you want them to be!)
• Audience segmentation – moving away from broad messages, segmenting people/tailoring messages
• Contrast with commercial marketing: profit goal
Health Promotion strategies
Social Marketing
Core concepts Adopts the ‘4Ps’ marketing mix:
• Insight – what the audiences wants and • Product – health
needs, understanding of everyday lives • Price – not always financial
and experiences
• Place – where to target your audience
• Exchange – what is the cost to the
consumer? What are they giving up? • Promotion – which media to use
Time, money, pleasure etc. How do you
enhance your offering?
• Competition – internal and external e.g. • Other ‘Ps’ - Partnership , Public,
pleasure, habit, addiction, time and Policy, Purse-strings
attention
Further reading
World Health Organisation – Health Promotion

https://www.who.int/health-topics/health-promotion#tab=tab_1

Centre for Disease Control: National Center for Chronic Disease Prevention and Health Promotion
(NCCDPHP)https://www.cdc.gov/chronicdisease/index.htm

Kumar& Preetha (2012) Health Promotion: An Effective Tool for Global. Health Indian Journal
Community Medicine.

Vanden Broucke (2020) Why health promotion matters to the COVID-19 pandemic, and vice versa.
Health Promotion International 35(2):181-186.

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Questions?