NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS Health promotion and health education: advancing the concepts Dean Whitehead Mse RN Senior Lecturer, School of Health Sciences, College of Humanities and Social Sciences, Massey University, Palmerston North, New Zealand Submited fr pubiestion 10 June 2005 ‘Acepted for publication 7 January 2004 Correspondence: Dean Whitehead School of Health Sciences, Collegeof Heaaniies and Social Sciences, Massey University, Private Bag 11 222, Palmerston North, New Zealand E-mail: davhitebead@mastey.s.ne Introduction WHITEHEAD D. (2004) Journal of Advanced Nursing 47(3), 311-320 ‘Health promotion and health education: advancing the concepts Background. Health education and health promotion activites are a fundamental requirement for ll health professionals. These two paradigms are closely related bist are not interdependent. Despite this, it is known that many nurses confuse the terms and use them interchangeably. With this in mind, it is necessary to re-conceptualize the terms in an attempt to bring them to a current form of ‘maturity Aim, ‘The aim of the paper isto provide an up-to-date analysis of health promotion and health education that serves as a conceptual and operational foundation for linickans and researchers. ‘Method. A concept analysis following the criterion-based methods described by Morse and her colleagues was applied to the terms health education and health promotion, using generic and nursing-related literature Results. ‘The conceptual literature on health education is consistent between generic and nursing-telated sources, On the contrary, earlier nursing literature on health promotion is now at odds with more recent socio-political and community action models of health promotion, in that it focuses on individualistic and behavioural forms of ‘health promotion’. A significant proportion of later nursing-related lit ‘erature, however, suggests a maturing of che concept that brings it further in line With a socio-political health promotion agenda, Conclusion. While the theoretical and conceptual lit ‘education has remained relatively constant and unchange ore surrounding health wer the last decade or s0, the same cannot be said for the health promotion literature. The evolving dominance of socio-political action in health promotion has overtaken individual- od forms. While the recent nursing literature addresses and acknowledges the place of socio-political activity as the mainstay of health promotion interventions, this is largely from a theoretial stance and is not applied in practice istic and behaviouraly-rlat Keywords: health promotion, health education, concept analysis, nursing professions have developed significantly over this period ‘Much hat occurred that now adds to Maben and Macleod [A clear conceptual framework is required as a foundation for cffective nursing-related health promotion and health educa: tion research and practice (King 1994, Kulbok et al. 1997) Nearly a decade ago, Maben and Macleod Clark (1995) presented a concept analysis of health promotion in this joumal. Health promotion and its luence on the nucsing (© 2004 Blackwell Publishing Lad Clark's seminal paper, and consequently a further concept analysis is now needed. This is often the case, much as Maben and Macleod Clark's concept analysis added to Brubaker's (1983) earlier linguistic analysis of health promotion in nursing. Concept analysis, therefore, is an evolutionary process based on the notion that concepts change over time sitD, Whitehead (Rodgers 2000). This underpins the aim of concept analysis to move concepts towards ‘maturity’ in the context of the ‘most recent thinking and developments (McCormack et al. 2002), and is necessary if practitioners are to be conver- sant with the latest developments in their health-related practices Maben and Macleod Clack stated in 1995 that little attempt had been made up to that point in the nursing literature to clarify what the term health promotion meant. Significant steps have been taken since then to do this, as ‘evidenced by the volume of post-1995 conceptual literature (ic, Kulbok ef al, 1997, Rush 1997, Morgan 8 Marsh 1998, Benson & Latter 1998, Robinson & Hill 1998, Norton 1998, Piper & Brown 1998, Whitehead 2001, 2003a). Conceptua- lization has been necessary for nursing, given 1 health education and health promotion are used on a daily basis with implied meanings attached to them. Concept advancement helps to move terms away from the realm of ‘everyday meaning towards more precise meaning and clatty the terms (Hupeey ef al. 2001). This paper draws on nursing.related and generic health promotion and health education literature to develop an up-to-date concept analysis. It does this using Morse’ (1995, 2000) and Moree et al.'s (1996a) processes of concept analysis. “The concept analysis Aim ‘The aim of the concept analysis ie to provide an analysis of health promotion and health education that serves asa conceptual and operational foundation for clinicians and researchers ‘Methodology Increasingly in the recent nursing literature, concept analysis is emerging as an important approach for exploring conceptual issues. Concept analysis is essential for three main reasons: concepts are development, analysis is requited if the concept is t0 be in nursing used in. theory ‘operationalized into an ‘instantiation’ of the concept, and it aids practice by offering a clearer understanding of what specific terms mean (Paley 1996). Maben and Macleod Clark (1995) used the method developed by Rodgers (1989) for these purposes, I have used Morse’s methods because 1 believe that they are less staged, positivist and de-contex- tualizing than other methods and subsequently they match more closely the philosophical underpinnings of health ‘Promotion practice. Its process involves review and critical appraisal of the literature in order to explore the ‘pragmatic uvility’ of concepts (Morse 2000), Literature search, ‘The extensive theoretical phase began with the collection and analysis of a broad range of health-related literature, ‘with a focus on the interpretation contained within it. The bibliographical databases CINAHL, Medline, ASSIA and journal database EBSCO were searched for the years 1995- 2003. These databases were deemed most appropriate because they use sources that directly relate to nuesing, medicine, allied health professions and health education! health promotion practice. The Key words used were “health promotion’ and ‘health education’, narrowed down later to include “health promotion theory’ and ‘health ‘education theory’. A secondary search was conducted by investigating the reference liste of the gathered literature. Literature that sought to define health education and health promotion or provide a suitable unit of analysis was included Data analysis Once the literature had been collected it was analysed to investigate the level of concept maturity. If the concept contained clearly delineated and defined characteristics or preconditions it was deemed mature. This proved to be the ‘ease with the concept of health education. With the concept ‘of health promotion, however, further analysis was needed to facilitate ‘concept clarification’, using the literature as data This is necessary where a large body of literature ‘exists and the concept already appears to be well described, but on closer reading the concept is often unclear and many “competing implicit assumptions’ are evident (Morse 1995, p. 42). Concept clarification has several stages but began in this case by posing analytical questions of the collected litera- ture (© uncover the nature of the conceptual immaturity. [Areas of existing or potential conflict were then highlighted and further examined. This stage was followed by several ‘others: ‘collapsing and combining’ analytical questions until an exhaustive list was obtained, returning to the literature to contrast these inguiries and compare congruence beeween different groups of literature and, finally, develop- ment of a provisional theoretical definition alongside a cleat ‘explication of the conceptual components (Hupcey et al. 2001). One of the main objectives of this concept devel ‘opment, therefore, was to identify and explore the concepr’s defining attributes. ‘The intended result was to achieve Bi © 2004 Blackwell Publishing Le, Journal of Advanced Nursing, 47(3), 311-320‘Nasng theory and concept development or analysis “conceptual order out of semantic chaos’ (Paley 1996, p. 573), Findings Whereas Maben and Macleod Clark (1995) attempted to beak down health promotion into the components of ‘health’ and ‘promotion’, I consider that the term is now established enough to be considered as a concept in its own right ~ as is the case with health education. Because it is possible to explore theoretically the paradigms of health ‘education and health promotion in their own right, the terms cean be separated from cach other. It is more in line with ccucrent thinking that the paradigms may be closely related but are not inter-dependant. Health education Theoretical definition For the most part, health education is consistently seen in the literature to have a nique and particular focus. ‘The health ‘education literature commonly describes it as having several functions and including actions designed to (a) impart health- related information that influences values, beliefs, attitudes and motivations; (b) achieve health- or illness related learn: ing through knowledge acquisition, assimilation and dis- ssmination and (c} lead to skills development and lifestyle! behaviour modification, These activities are generally tar- gered at the level of individuals and are identified within a framework of activities that range from information-giving through to enabling processes. Thus, health education may be dofined as follows "Hielth education ie an activity that seks to inform the indivi on the nature and causes of healthllets and that individual's petsonal level of risk associated with ther lfestyleelated behaviour. lealth ‘education ecks fo motivate the individual to accept a pracest of Dehavioural-change through directly influencing ther value, belief and attitude systems, where it i deemed that the individual is particularly at sak or has already been affected by ilnssdisease of ability Antecedents TThe antecedents to health education are that the individual is in need of health-related advice in order that they can make sense of their actions and behaviours and, consequently, will act on any tensions that may arise. It is assumed that an individual values and prioritizes their health as important and that i is reasonable for che health professional to act on the basis thatthe individual wants to avoid or reduce any negative Health promotion and bealth education health state. Health education assumes that the health professional has the necessary health-related information to jmpart and that the recipient is in need of and will benefit from this information. A farther assumption is that if the recipient hhas correctly assimilated and disseminated this information, any further action on their part will involve change or modi- fication in their behavioue. Recipients may be supported through this process, but are ultimately personally responsible for any action that they may or may not undertake. Attributes Health education information is designed to influence the knowledge-base of a client as well as their attitude, value and belief systems. This then leads to a conscious personal decision to change existing unhealthy behaviour or to avoid ‘unhealthy behaviour in the first place. The client and health professional adopt one of two broad approaches. Fitst, a ‘medical approach, as a reactive and opportunistic process, may be adopted where the client has an existing condition or illness. Secondly, a preventative approach is a more proactive method adopted where the client does not have an existing condition or illness but may be at isk ifthey continue with or take up certain health-damaging behaviours. The attributes ‘of health education ean be summarized as: + the intention to alter/modify health-damaging behaviours where identifiable and measurable risk factors are known; ‘+ the willingness of individuals to participate in ‘expert driven’ programmes of behavioural change in exchange for 4 reduetion in risk of illness or disease and with the expected outcome of improved health status — usually physical, Outcomes The outcomes of health education may be positive or negat- ive, The professional intention is that the ‘education’ will culminate in behavioural change and lead to a positive health status outcome, On the contrary, the outcome may be adverse if it ig ill-conceived and demands unrealistic and unsupported outcomes that are not based on the priorities or preferences of the recipient. Successful or non-rucceseful outcome is related to the degree to which the recipient values the change and believes that they are capable of producing it {health efficacy) The nursing-related and generic literature on health ‘education is comparable and consistent. Its process and systematically presented (Whitehead Russell 2004) and the concept appears to be mature, with clear concept development and delineation I meets the seria for concept maturity in that the concept is labelled, (© 2004 Blackwell Publithing Lt, Journal of Advanced Nursing, 4713), 11-820 318D, Whitehead has a meaningful definition and har well-delineated boundaries (Morse et al. 1996b). This analysis of health ‘education provided the basis for what is referred to as ‘concept refinement (Hupcey 1998). This conceptual delin- cation and maturity, however, was not found in the health promotion literature and, according to Tones (2002), the conceptual clatification and defining of health education is a far easier and less controversial task than that for health promotion, Health promotion Theoretical definition The recent literature sreses the socio-political nace of health promotion far more than was the case in the pat Health promotion activities are by their nature inherentiy politically based and driven, thus making it impossible 10 divorce them from the political arena. Health promotion acknowledges tha RR TEI PS RSCOOTSBIEGE -tesponsible for their own health status, and that strong, ‘extemal elemental WaVSNPIAW! Broader determinants of health, such as ecological, cultural, economic and envio rental factors, are known to determine th level of health of individuals and communities, and all have political under Pinsings within an ‘enviromental engineering? proces The health promotion literature, over the last decade of 10, has demonstrated a move from individual empowerment programmes to far more emphasis on policy that work through social examination and modification, particalarly atthe level of collective action, Health-promo- ting empowerment activites are BOtiealSEeTEHE ATA ‘CHEGNLINIAAAAMAATHus health promotion may be defined as follows: Health promotion 5 the process by which the ecologically deiven (GHEE This serves to counter socal inaction and socal division! ‘inequality. Iti an inherently politcal process chat draws on health policy asa basis for social action that leads to community coalitions ‘through shared radical consciousness. Health promotion 2ecks to radically transform and empower communities through involving them in activites chat inluence heir public health ~ particularly via agenda setting, poitieal lobbying and advocacy, rtical conscious nesstalsing and social education programmes (see Whitehead 12003). Health promotion looks to develop and reform social Antecedents ‘The antecedent to health promotion is the premise that the health of individuals aze intertwined with the collective health of the communities in which they live and by which they are served, Most individuals are powerless on theit own, to influence the overall health of their own communities, and therefore need to be collectively morivaced, mobilised and ‘empowered to develop political strategies in order to over- ‘come structural dilemmas and inequalities. Health promotion is underpinned by the principles that an individual values and priorities their and their neighbours’ health as important and that they willingly take on a representative role that facili= tates community action. It recognizes that empowered com- munities have a much greater health impact than individuals cor small groups. ‘The role of health professionals is acknow- ledged, but itis assumed that their incervention is only likely to bea transitional phase, designed ro provide support and set ‘up necessary resources for community reform. Potentially, ‘the community empowers itself politically to become self resourcing and collectively empowered - but acknowledges that health professionals are an integral part of the commu- nity. Effective health promotion also assumes that health professionals are themselves autonomous, empowered, politically motivated and able to move freely in and out of health service arenas, Implicit within this is that health pro- fessionals understand that health promotion strategies are deeply rooted in mult-professional and multi-agency colla- boration, No individual health professional or single profer- sional body can perform health promotion on theit own. Attributes Health promotion aims to support communi ‘members who are affected by and wish to contribute to the socio-political, environmental and ecological determinants of | ‘GIEhWithRIRLORENCOMMIMITIES It does so particularly through political processes such as critical consciousness- raising, agenda setting and lobbying, It draws on a range of, health professionals and agencies to support and resource local community health aims, particularly through partici» ating in social, environmental and health policy reform and ‘encouraging its citizens to do the same. Communities are thus ‘empowered to take on social action roles that facilitate the development of social capital as the health-related link beeween social structure and human agency. Social capital is “the total of social elements which are required for the development of human capital’ (Keitsotakis 8¢ Garmarnikow 2004, p. 44), Iris tightly linked to the concepts of community networks, civic identity and engagement, reciprocity, parti- cipation, social engagement and mutual trust (Cambell etal ss and their Bi © 2004 Blackwell Publishing Le, Journal of Advanced Nursing, 47(3), 311-320‘Nasng theory and concept development or analysis 1999, Hyyppa & Maki 2003). Itis achieved by health pro- fessionals primarily through theie contribution to social and ‘economic policy asi affects public health issues. Community empowerment, community competence and sense of com- munity all contribute to the public health of communities (Edmondson 2003). Public health, therefore, is synonymous ‘with health promotion in that it aims co implement co-ordi- nated community action to produce 2 healthier society. ‘Therefore public health policy, as a comerstone of commu- nity development, is necessarily politcal in order to create health-enhancing environments, The attributes of health promotion ean be summarized as: «the need and desire to develop and implement community driven health reform based on social action, social cohe- sion and social capital, + the willingness of communities to become empowered and self-reliant in determining collective health needs and pri- ‘the attainment of health gain asa fundamental priority and shared social objective of community action; ‘+ the active development of public health poliey by com- munities as it applies to those communities. Outcomes Health promotion is filigal Giviey Aha promises AanA® “mental reform of health structures within communities and (SOGIRELASTANWAHGLE? Its outcomes can be both positive and negative. A positive outcome generally relies on the capacity and willingness of communities, and the individuals in them, to become politically and socially empoweredieelf-reliant, 20 that they can prioritize and act upon health issues based on local need. Negative outcomes occur where professionally paternalistic and disempowering health policy decisions force ‘CRRIEHERRLAREMNGECOHAES that are irrelevant to sustained community development and are not based on or resourced according co the social reality of that community. Further- more, there is potential for communities to become intro- spective and insular as they seek to protect their hard-earned gains, to the exclusion of neighbouring communities and the population as a whole Discussion It is important that health professionals are able to define theoretically and delineate exactly what constitutes both health education and health promotion practice. Elfective health promotion and health education practices are depend- ent on sound theory (Caplan & Holland 1990). Clear conceptualization acts ar a baseline to validate current practice and serves as a springboard for innovation and Health promotion and bealth education advancement. Morgan and Marsh (1998) state that, although. the concept of health promotion in nursing has evolved, its efinition still remains too broad. Therefore, it is necessary to identify how the current literature defines today's health ‘promotion against that of past definitions. For instance, what ‘Maben and Macleod Clark (1995) and Benson and Latter (1998) refer to asa traditional approach and a new paradigm approach to health promotion have become redundant. Similaely, Kulbok et al, (1997) use the term behavioural health promotion to denote a supposedly new paradigm approach, These authore refer to approaches that involve individualistic and behaviourally-orientated ‘empowerment fas the mainstay of health promotion. Particularly at a political level, however, Robinson and Hill (1998) argue that this individualistic orientation is a major obstacle to current nursing-related health promotion practice. To continue using the label ‘new paradigm’ to describe health promotion in nursing would necessitate that we now acknowledge a ‘newer’ paradigm approach v0 denote the ‘emergence of a far more politically-orientated empowering health promotion paradigm. This is especially so because health-promoting empowerment approaches ate often mis- construed within the nursing literature. MacDonald (1998) argues that most health professionals are notin a position to ‘empower clients and instead are only in a position to offer impowerment, In this context, empowerment is facilitated through a client’s own endeavours without reference to an authority, while impowerment is power conferred on clients by someone in authority. To compound the health promotion ‘empowerment issue in nursing, some of the current literature disputes the place of bchavioural/individual empowerment as ‘valid form of health promotion. It states that these activities are instead properties of ‘progressive’ health education activity. Piper and Brown (1998) make this distinction in referring to the Patient Information Model to denote a limited form of health education, as compared with the Patient Empowerment Model that addresses a less limited and more enabling type of health education, Empowerment, in current health promotion terms, means ‘moving away from an individual and behavioural orientation towards more collective community-based action, It is primarily concerned with empowering citizens to take control ‘of their health through methods such as community devel- ‘opment, political advocacy, formulating integeated health strategies and social marketing (Webster & French 2002) Of course, this does not preclude individual empowerment srategics or fail to acknowledge their usefulness, but makes the crucial distinction between individual and community empowerment. According to Wallerstein (1992, p. 200}, health promotion empowerment is: (© 2004 Blackwell Publishing Le, Journal of Advanced Nursing, 4713}, 11-820 sisD. Whitehead ‘A sociab-action process that promotes participation of people, ‘organisations and communities towards the goals of increared individual and community contol, politeal efficacy, improved ‘quality of life and social justice While empowered individuals may at first be needed to ‘mobilize communities, an empowered community generates norms and support systems that enable individuals in greater numbers to acquire the competencies and characteristics of selfempowerment (Tones 2001). In effect, this suggests that a better strategy for empowering more individuals lice not ‘with individual empowerment programmes, but with the filtering-down process that accompanies a whole community action empowerment strategy: ‘The World Health Organization (WHO) has attempted to move the definition of health promotion away from a _medicalipreventative focus and towards the health and well-_ being of whole populations, so that the citizens of local communities politically control the determinants of health that are relevant to them (WHO 1984, 1986). Central co the: tenet of health promotion as a developing ideology are the politically-driven processes of the ‘new" public health move- ‘ment (Macdonald & Bunton 2002). Once seen as competing and different concepts, public health has more recently allied itself to health promotion to the extent that politically, ‘economically and socially they are almost indistinguishable from each other ~ or that public health is essentially a sub-set ‘of health promotion (public health promotion) (Oakley &¢ Oliver 2001, Webster & French 2002), Harrison (2002) suggests that it ie no longer tenable to separate the disciplines ‘of health promotion and public health where a wider agenda of sustainable human development applies While many of che earlier conceptual nursing articles mention socio-political nd community processes, they do s0 as addons and mainly refer to socio-political processes a8 health promotion at its broadest level. Socio-political process, however, is fundamental to all current health promotion activity. Subsequensy, a huge amount of nursing lierature has recently emerged that stresses the health promotional socio-political role of nurses in relation to health policy and public health processes. (e.g. Antrobus & Kitson 1999, Falk Rafael 1999, Gebbie eal. 2000, Spurgeon 2000, Score & West 2001, Des Jardin 2001, Whitehead 2003h). ‘Tis emphasis is also the case in relation to nussing education (i.e. Callaghan 2000, Conger & Johnson 2000, Clifford 2000, Cohen $¢ Milone-Nuxz0 2001, Liimatainen tal, 2001, Whitehead 2002, 2003c) Fourteen years ago, Tones (1990) argued that lobbying and advocacy for political change should be the main focus of health promotion, and this has now happened, Activites that cdo not inchude politially-orientated empowerment strategies may not now be categorized as health promotion (Macdonald & Davies 1998, Tones 2000). According to Jones and Douglas (2000), the more recent emphasis on health promotion as a radical socio-political process has been “asiking’. The majority of current health promotion literature sxcesses its socio-political contribution over any other aspect ones 1997, Whitelaw ef al. 1997, MacDonald 1998, Tones 2001, Tones & Tilford 2001, Harrison 2002), Health promotion is in itself a political process. It is a radical activity that poses fundamental questions about the way that society is organized and how this directly impacts on the health of populations (Victor 1995}. As Harrison (2002, pp. 164-165) suggests: population health is realy an outcome of "emergent capacity’ arising from the effects of health-related soci], economic and cultural activity and investment.) requites concerted, sophis ‘ated and integrated politcal action to bring about change and ‘requires professionals concerned with public health to engage with the pois of system and organisations, ‘Therefore, health promotion is currently represented mainly by activities that build healthy public policy and strengthen ‘community action in order to achieve social cohesion and capital. The goal of health promotion is thus the facilitation ‘of concerted social empowerment that creates ‘full and ‘organised community participation and ultimate self-reliance” (Yeo 1993, p. 233). McMurray (1999, p. 262) indicates that the most significant shift in conceptualization and emphasis in health promotion has been: from teaching people how so manage their health (individual! behavioural orientation] toa more socially embedded approach that capitalises on the inherent capacity of community members £0 establish their own goals, strategies and priorities for health.a socioecologcal, community development approach to community bale, Rawson (2002) confirms that $i OIRicaISOrGnrEa GOR. munity development approaches are the most “authentic” oF ‘ideal form of health promotion"practice, Furthermore, health promotion strategies acknowledge differing forms of, ‘community. For instance, the ‘global community’ secks to develop progressive social change via an credible interna- tional public health agenda (Harrison 2002) and find relevant political answers to problems such as new diseases (i.e. SARS, HIV}, the impact of wars and other humanitarian disasters “To clatify farther the points made in the last few paragraphs I refer to the fact that, according to Ewles and 316 © 2004 Blackwell Publishing Le, Journal of Advanced Nursing, 47(3), 311-320‘Nasng theory and concept development or analysis Simnett (1999), there are five distinct approaches to health- related practice. For the sake of conceptual clarity I have adapted these approaches and refer to them as medical, preventative, educational, empowerment and socio-political In the case of this concept analysis, [argue thatthe literature now tends to refer to medical and preventative approaches as ‘most likely to fll within the ambit of health education, while ‘empowerment and socio-political activities are more com: monly termed health promotion. This suggests that certain health-related approaches sit in the closely related yet independent paradigms of health education and_health promotion, This aids delineation of the concepts. If most nursing health-related programmes come under the auspices ‘of @ medical or preventative approach, then clearly they constitute health education and not health promotion, Alternatively, any nursing activity that involves ecologically- and enviconmentally-diven action and sed mamnunity- empowerment would correctly be termed health promotion “This analogy leaves the educational approach somewhere in the middle, serving as an enabling/individual ‘impower: ment? process that bridges the gap between the two paradigms and demonstrates their inter-relatedness (White- head 2003a}. The extent to which the educational approach sits more closely with either health education or health promotion will depend on the degree to which it is structured to facilitate individual enablement or community-based empowerment. The educational approach is perhaps most realistic for the majority of nurses to strive for, given the constraints of health service settings. It is an approach that could also serves as a useful catalyst for initiating and driving furure community-empowerment and socio-political health promotion practice. However, individual health educ interventions may complement, but do not constitute, the collective action that underpins health promotion (Piper & Brown 1998). Therefore, social action may involve elements ‘of education but itis essentially a radical politcal process (French 1990) acknowledge that providing a ‘final’ definition of health promotion is an impossible task. To demand conceptual clarity within all of the health promotion/health educ literature is somewhat naive. The “exact” point of demarea- tion may not be clear, For instance, at what point docs a ‘wide-ranging health education strategy that may involve lements of empowerment or politcal process cease to be health education and become health promotion and vice ‘versa? The operationalization of concepts is difficult because it s unlikely tha there is ever going to be only one theory for whatever is being investigated ~ therefore to demand aniver- sal agreement is ‘unreasonable’ (Paley 1996). To leave a concept wide open so that it is used as an interchangeable Health promotion and bealth education ‘catchall? term, however, is highly problematical - especially in the case of health promotion. Conclusions A carrent concept analysie ie only the starting point for concerted health promotion reform in nursing. A clear concept of health promotion, and for that matter health education, must subsequently be followed up with a concer- ted effort to implement effective programmes in nursing practice. Despite a clearer theoretical definition of health promotion, there is still very litle nursing work that is credibly linked to health promotion strategies direct impacting socio-politially on communities (se, for example, ct al. 2000, Huyhn ef al 2000, Westbrook S Schultz 2000, Kraus etal. 2003). This is not to say that nurses are not involved in radical health promotion programmes, but where they are they may not be initiating, evaluating or clearly disseminating these activities. For instance, Graney (2002) states that the individualistic orientation of comme: nity-based nurses stil fail to recognize the importance of community health-oriented health promotion activities. Also, Dalziel (2002, p. 220) argues chat what is missing from primary care isthe ‘action part’ of community development because collective action ie still ‘scary’ for nurses in thie setting. Anderson et al. (2002) offer a theoretical model that addresses these issues. ‘Therefore, current health promotion strategies require not just a different mindset, but also a different way of working. The shift that is required is highlighted by Harrison (2002, p. 175) The health development professions including nurses] must ally ‘themselves with cvie soiery in the development of systems of heals governance at cach level of rocal and economic administration, They smust network their knowledge and skill across all levels, systems sectors and professions. They must poitiallyinervene within the ‘social machinery’ of the state and within all forms of social ‘organisation and systems where decisions are made and resources alloated, They mut join in the wider social project of surtsinable ‘homan developmen at every level, érom local to global ‘Teying to define current theoretical frameworks for health promotion, as in this paper, is vital. Rawson (2002, p. 267) suggests that ‘the asking will help better define the sub- ject matter and create the discipline to discover the true potential of health promotion’, while French (1990, p. 12) ‘This not simply a matter of semanti refinement; what i at stake is the very practice of health promotion and the postion it adopts based on a particular view of the wosld. (© 2004 Blackwell Publishing Lt, Journal of Advanced Nursing, 4713}, 11-820 3i7D. Whitehead What is already known about this topic «+ Linguistic and concept analyses of health promotion in pursing have been developed, the first over two decades ago and the second nearly a decade ago. ‘+ “Health promotion’ is based on political and community empowerment-driven processes, whereas “health edu- cation’ has remained unchanged for many decades and emphasizes individual and behaviourally focused activites. What this paper adds + Further conceptual clarity based on existing interdisc- plinary theoretical definitions and usage, reflecting the theoretical basis and maturity of health promotion and. health education, + An up-to-date conceptual and operational foundation for clinicians, theorists and researchers. + The concept of health promotion cannot be fully wunderstood and acted upon without an accompanying concept analysis of health education that distinguishes between the two. + The importance of nurses working collaboratively to influence the socio-political determinants of social action, cobesion and capital in the communities they Whitelaw et al. (1997) also suggest thar Kigali SFOS “not only judged on its actions but also on its capacity to developlanibpropriateltheoreticaltagends. To bring about broad health promotion reform, a radical “refocusing ‘upstream’ is required that generates social and political activism in nursing. This necessitates that nurse's step outside traditional roles and boundaries in order to adopt broader health promotion roles, It requires a mobilization of appro- priate strategies that bring about measurable organizational and community change ~ such as employing participatory action research activities (Flynn ef al. 1994, Tones 2000, Clark etal, 2003, Whitehead et al, 2003), Nurses also need to make inroads into wafamiliar territories if they wish to engage in wide-ranging health promotion reform, such a influencing media advocacy initiatives as a means of critical constious- nese-rising for political change (Chapman & Lupton 1994, Holder & Treno 1997, Whitehead 2000, Stead et al, 2002), These activities can sit within and alongside traditional, yet valid, individual empowerment programmes, This said, what the future holds for health promotion in nursing seems clea it i the advancement of a socio-politically-oriented and ‘community-driven social eapital agenda, References Anderson D., Guthrie T. 8 Schtle R. 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