WEEK 2: HEALTH PROMOTION THEORIES

Learning Objectives

• Understand the relevance and role of Health Promotion.

• Explore the theoretical frameworks and models used in Health Promotion.
• Consider the role and appropriate practices of professionals in promoting health

Contents
Learning Objectives ................................................................................................................. 1
The difference between prevention, health promotion and health education ....................... 2
Theoretical models and approaches to health promotion ...................................................... 3
Tannahil model of Health Promotion ...................................................................................... 3
Tones and Tilford’s model of Health Promotion ..................................................................... 5
Beattie’s model of Health Promotion...................................................................................... 6
The different approaches to Health Promotion ...................................................................... 7
The characteristics of an effective health promotion professional ....................................... 11
Developing specific skills for performing health promotion activities................................... 12
Ethical issues and related dilemmas in health promotion..................................................... 13
References ............................................................................................................................ 16

1
The difference between prevention, health promotion and health education
It is important to distinguish between the concepts of "prevention" and "health promotion".
Both concepts have a common goal: to improve the health of the population. However, they
should be understood as complementary approaches to addressing public health problems in a
population (Elaine Auld et al., 2011).

As we saw in the previous chapter, prevention has a pathogenic focus, focusing on diseases
and illnesses, with close links to the medical and biological sciences, and aims to prevent
diseases by reducing or eliminating risk factors that cause poor health. Prevention can be done
on an individual basis (e.g., breast cancer screening) or on a population level (e.g., chlorination
of water sources). Prevention (primary, secondary and tertiary) includes interventions such as
anti-smoking campaigns, or the treatment of high blood pressure. Moreover, prevention does
not focus solely on the individual, but takes on a community or population perspective (Dans
et al., 2011).

Health education is about providing health information and knowledge to individuals and
communities and developing skills that will enable individuals to voluntarily adopt healthy
behaviours. It is a combination of learning experiences that aim to help individuals and
communities improve their health by increasing their knowledge or influencing their attitudes
(Elaine Auld et al., 2011).

The much newer concept of "health promotion", on the other hand, uses a reformed approach
that focuses on health and the factors that maintain or lead to good health or disease. This is
achieved with a multidisciplinary philosophy, which concerns not only the public health
sciences, but also the economic, political, cultural and social sectors. Essentially, health
promotion adopts a more comprehensive approach to health improvement, with the
participation of various actors and focusing on multidisciplinary approaches. Health promotion
has a much broader perspective and is adapted to developments that are directly or indirectly
related to health, such as inequalities, changes in consumption patterns, environmental
components, cultural beliefs, etc. (Dans et al. , 2011; Lucas & Lloyd, 2005; Muruktla et al.,
2018).

2
Theoretical models and approaches to health promotion
In the context of the effort for the best practice of health promotion but also the creation of a
theoretical field for the promotion, the experts of the field, have developed different models,
which represent real conditions and highlight the relationships that develop between different
participating factors.

The existence of these models, although not absolute guides for health professionals, can help
to capture the theoretical background of health promotion better, to evaluate and analyse
existing practices and to design future ones more effectively. Τhe literature reveals a number
of such models which use different terms and employ different criteria. However, they all offer
the opportunity to health professionals to recognise the different options and possibilities, to
evaluate them and in this way, in the long run to contribute to the effectiveness and adequacy
of the health promotion practices.

Tannahil model of Health Promotion

This model (Downie et al., 1996) is one of the most accepted and widely used models of the
field, which is characterised by the existence of three cycles of activities, interconnected, as
shown in Figure 1.

Figure 1: The Tannahil model of Health Promotion

3
 Source: Oxford medicine online

The three cycles include the concepts of health education, prevention, and health protection:

• Health Education: In this model health education is defined as any effort to prevent
poor health and encourage well-being, influencing the knowledge and attitude of
individuals.
• Prevention: Prevention refers to the effort to reduce or avoid the risk factors associated
with the disease, mainly through medical interventions.
• Health protection: This term refers to any effort to protect the health of the population
by taking legislative, social, and economic measures.

As shown in the diagram, the three different approaches described in the cycles are interrelated,
making up the overall process called Health Promotion. The numbers shown in the circles
represent the following corresponding activities according to this model:

1. Preventive services, such as vaccination

2. Health education aimed at prevention, such as anti-smoking programs.
3. Preventive activities to protect health such as water chlorination.
4. Education for the development of preventive services and health protection, such as
making contacts to promote legislation on the use of seat belts.

4
 5. Positive health education activities such as the development of Health Education
programs for the development of health skills.
6. Positive health protection activities, such as anti-smoking legislation at the workplace
7. Health education, which aims to protect health, such as promoting the ban on tobacco
advertising.

This model helps the health professional to understand the broader purpose of health promotion
and to realise great potential to mobilise and become active in many areas and fields. However,
although it describes the promotion of health in practice, it does not provide the necessary
information as to why health professional should use one activity over another, and this is
precisely its weakness which is the main criticism of this model.

Tones and Tilford’s model of Health Promotion

At the core of this model is the concept of self-empowerment. Self-empowerment is both the
desired goal, so that individuals can develop control over their health, as well as a basic strategy
that should be adopted by health promotion professionals in their daily practice.

According to this model, the process of health promotion is the result (product) of an equation,
according to which:

Healthy Public Policy x Health Education = Health Promotion.

The founders of this theory reduce education and training to basic methodological levers that
promote self-empowerment (Tones & Tilford, 1994). With health education, both the public
and the health professionals themselves increase their levels of sensitivity and knowledge
regarding health issues, and thus increase their potential to adopt healthy behaviours and
stances, and push and demand for healthy public policies.

In this model, individual empowerment and community empowerment work mutually. Thus,
changes that are realised in the context of the social environment with the implementation of
healthy policies, promote the development of self-empowerment in individuals. Accordingly,
when individuals develop skills that result from self-empowerment, such as greater

5
involvement in health decision-making, then they can more easily influence health policies and
use available health services more effectively. This model essentially argues that prevention is
not the main goal of health promotion, but rather self-empowerment is what can make
individuals and communities able to increase control over their health.

Beattie’s model of Health Promotion

This Health Promotion model is considered to be one of the most useful, as it enables promotion
professionals to choose appropriate promotion strategies, taking into account the fact that these
strategies can be influenced by the political and social environment in which they take place.
The model highlights the existence of four models - health promotion strategies, which are
characterised by different goals and activities, but at the same time, are governed by different
political ideologies (Naidoo & Wills, 2007). More specifically:

1. Health persuasion: The strategies that fall into this category are those that are designed
by experts, aimed at individuals, and aimed at adopting a healthier lifestyle. The
activities that fall into this category are the provision of information and counselling.
The health professional attains more the role of the specialist, while conservative 1
ideology is governing this category.
2. Legislative action: This category includes interventions designed by experts and
addressed to the community, in order to make healthy choices easier, for the sake of
protecting the health of its members. In order to achieve this goal, activities are
developed at the level of political action. Here the health professional performs more
oversight duties, as he/she knows what can contribute to the health of the population.
The political ideology that characterises this type of activity is the reformist.
3. Personal counselling: This third category includes interventions that are designed to
empower people, to develop the necessary skills and self-confidence, in order to gain
control of their health. The health professional has mainly a consulting and supportive

1
The cautious and conservative treatment of new institutions, principles and values of society, on an
individual and group basis.

6
 role; he/she cooperates with the person based on their personal needs, as the person has
defined them. The activities that belong to this category are counselling and education,
while the political ideology that characterises it is the humanistic 2.
4. Community development: Within the framework of the fourth and last category of the
model, interventions similar to the third are included, but which are designed with the
aim of strengthening the communities or groups. That is, communities and groups
should acquire the necessary skills that will allow them to gain control of their health.
The main role of the health professional here is supportive and is carried out through
activities such as community development, and community action. The political
ideology that characterises this category is radicalism 3.

The different approaches to Health Promotion

The existence of the above theoretical models of health promotion highlights, among other
things, the fact that the practice of health promotion is not limited to one approach, but there
are different methodological approaches. These approaches differ in terms of their purposes
and methodology. Subsequently, while some approaches are aimed at preventing the disease,
others contribute to the enrichment of relevant knowledge and others to greater control over
health by developing appropriate skills or changing environmental and social policies in order
to facilitate it. The above objectives may be attained by practicing five basic approaches
(Naidoo & Wills, 2000; Ewles & Simnett 2003):

1. The preventive approach

This method is mainly aimed at reducing morbidity and early mortality, with the development
of preventive services, which cover all three levels of prevention (see week 1). These activities
can be aimed at the whole population or at groups of comprised of individuals who are
characterised as high-risk groups. Methodologies that are part of this approach are screening,

2
Puts human beings and their needs at the centre of every activity and as the central axis of every decision.
3
Suggests political principles focused on changing social structures through revolutions or other means and
changing value systems in fundamental ways.

7
vaccination, etc. This approach, although extremely widespread, and with great interest in the
field of public health, does not emphasise the concept of positive health (see week 1), as its
success consists essentially, in the reduction of diseases, with practices based mainly on
medical knowledge and management and not on the autonomous action of individuals.

Figure 2: Phases of Prevention

Treatment

Health Primary Secondary Tertiary

Promotion Prevention Prevention Prevention

Susceptibility Pre-symptomatic Clinical Disability

Health - risk factors Disease Manifestation
-no signs -signs - signs
-no symptoms - no symptoms - symptoms

2. The behavioural change approach

The activities that fall into this category are mainly aimed at modifying behaviour and adopting
a healthy lifestyle. These methods are mainly aimed at the individual, but in order to attract
and inform the public about its benefits, they often use the media. Human behaviour is as
complex as the individual, and for this reason, as discussed in the next chapter, various theories
and models have been developed that attempt to explain the process of shaping and modifying
it. Behaviour change is a key element of most health promotion activities, as it is considered
that this emphasises the individual's participation in their health, and the individual is able to
change and improve their health. Models that study behavioural change, recognising that it is
greatly influenced by the physical and social environment in which the individual lives, have
evolved significantly, taking into account these parameters as well. The most difficult task in

8
the context of this approach is to evaluate its results. Human behaviour depends on a number
of factors and so it is often difficult to attribute its change to a health promotion intervention,
while behavioural changes are not always immediate.

Figure 3: The Stages of Behaviour Change (Prochaska model)

Source: Prochaska & Velicer, 1997

3. The empowerment approach.

Empowerment is a key concept in promoting health, as it helps to increase people's control

over their health, a fact already described as a key goal of health promotion. Empowerment
strategies concern both the individual (self-empowerment) as well as the empowerment of
communities. With empowerment, individuals and societies develop, evolve, or acquire the
necessary skills and competencies that will enable them to recognize their personal health
needs, but also the ways in which they will be able to act to meet them. In the context of these
approaches, the health professional does not have the role of the expert who dogmatically
proposes, but that of helping and supporting individuals and communities to identify and
process the desired changes. As in the case of behaviour modification, so in the case of

9
empowerment, evaluating health promotion interventions is a difficult process, as
empowerment does not happen automatically but requires a degree of time.

4. The educational approach

The primary purpose of this category of approaches is to provide knowledge and information
and to develop skills that allow the individual to act and behave in relation to their health,
making choices based on knowledge and understanding. Of course, this approach is based on
the view that education can bring about changes in behaviour, by influencing attitudes and
perceptions. Basic methodologies developed in the context of this approach are the distribution
of brochures, or other appropriate educational material, counselling, the implementation of
educational programs, as well as other passive or experiential methods. In either case, a change
in the level of knowledge, attitudes and feelings or abilities of the individual or group may be
sought. The success of this approach depends, to a large extent, on the competencies of the
health professional, while the evaluation in contrast to other approaches is easier, as the
acquisition of knowledge can be methodologically easier to measure.

5. The social change approach.

In this approach, the recognition of the importance of the social environment in determining
health is identified. The main goal is to create environments that support health and that allow
the individuals to change their behaviour, to adopt a healthier lifestyle, facilitating and
promoting these changes and the reduction of social inequalities, which are clearly obstacles
to this (see week 1). Interventions aimed at social change are a difficult task for the health
professional, and a great challenge, as they require special knowledge, skills, and training. The
activities are addressed both to the whole population and to the individual, while for their
evaluation; there is in place and development of legislative and organisational measures such
as the ban on smoking in public places, the development of green spaces, leisure, etc.

10
The characteristics of an effective health promotion professional
In order for health promotion to achieve the goals and objectives it sets, it requires health
professionals working to achieve them, to develop specific characteristics and skills, many of
which may not be part of their basic education but are acquired over time with daily
engagement and practice. However, it is extremely useful, especially for young aspiring health
professionals, who want to make a real contribution to the protection and promotion of health,
to be able to identify some key characteristics that will help them develop the skills and abilities
that will maximise performance and facilitate their challenging work.

Health promotion is a field that often requires the development of collaborations both between
different health professionals and with people of other specialties, whether it is other scientists
or politicians, technocrats, and bureaucrats, but also with lay people and of course with targeted
populations. An essential element of collaboration, and therefore a necessary skill for the health
promotion professional, is the ability to communicate. In order for the communication and
therefore the cooperation to be effective, two basic conditions must be met (Ewles & Simnett,
2003):

1. The health promotion professional should seek to follow the views and positions of the
people with whom he/she works.
2. Communication and cooperation should be based on mutual respect and trust and on
understanding the potential of all those involved.

Developing a communication plan is also a tool for the health professional. This plan should
record the available communication channels (face to face, written media, electronic media),
as well as the frequency of communication. It is also useful to record comments regarding the
quality of communication, any problems that arise, and to seek solutions. The development of
such a detailed communication plan should be based on the general organisational,
administrative, and coordinating principles that the health professional should develop,
depending on the role he/she assumes (Naidoo & Wills, 2000).

Another key feature that governs the ability to work effectively is coordination. This role
entails specific tasks and obligations which require the health professional to have appropriate

11
skills and abilities. The coordinator must enjoy the acceptance of the team, have organisational
skills, and facilitate the smooth running of the team. Among the main features of a teamwork,
which have been recognised as necessary for the development of effective collaborations are:

 The existence of a common purpose;

 The commitment of the team members to the goal;
 The selection of team members based on their specialised knowledge and skills;
 The awareness of one’s role and the role of the other members;
 Full mutual support;
 The complementarities of the knowledge and skills of the team members;
 The existence of coordination and guidance, by a specific person who assumes the
relevant responsibilities.

Developing specific skills for performing health promotion activities

Health promotion enables the professionals to work using various methods, approaches and
techniques. In this way, they can work in the design of education and health promotion
programs, in counselling and education, in policy making, etc. This range of activities also
highlights some of the key competencies that health promotion professionals should strive to
develop, without which the task of health promotion professionals becomes more difficult.
Some of the key competencies of health promotion professionals (but not limited to them)
include (Ewles & Simnett, 2003):

• Ability to design, implement and manage health promotion programs: In the weeks to
follow there will be an analytical description of the implementation and evaluation plan
of health promotion activities, from which it follows that professionals must develop a
range of competencies which include resource management, and systematic recording,
analysis and evaluation.
• Communication skills: Communication skills relate to contacts with associates, the
public, and any other person or group that may be involved in the process of conducting
health promotion activities.

12
 • Educational skills: Health education, counselling, as well as other health activities, rely
heavily on the ability of the health professional to impart knowledge, skills and
competencies related to health.
• Marketing and information dissemination skills: Professionals are called upon to use
the media for the benefit of health promotion, which in order to do so requires the
development of appropriate capabilities such as the development of appropriate
messages, the use of all necessary communication channels, publications, and the
development of collaborations with local and international media.
• Influencing skills and shaping of health policies and practices: Professionals in the field
should be able to recognise the forces that shape health policies, both locally and
nationally and internationally. Influencing policies is not just about making decisions
by people at the forefront of politics, but also about health policies adopted by various
organisations, such as the workplace and the school.
• Evidence-based health promotion: An equally important skill concerns the adequate,
production and utilisation of scientific information and available knowledge, which can
highlight what, constitutes success and what not, in the context of the implementation
of health promotion. Evidence-based health promotion is an approach in which a
collection of quantitative and qualitative data is carried out which contribute to the
formation of knowledge regarding the possible practices and methodologies in the
context of introducing health promotion activities. This approach has contributed to the
scientific validity of health promotion activities but much more, it is a valuable tool for
professionals in the field as it allows them to distinguish which method, or approach, is
the most appropriate and effective for their purpose.

Ethical issues and related dilemmas in health promotion

The daily practice of health promotion can easily reveal issues, which have an ethical basis,
and which the professional needs to address. One of the main aspirations of professionals in
the field is to contribute to the improvement of the level of health and to achieve this, specific

13
decisions must be made, which are based on the judgment of professionals, which in turn is
shaped by the spirit of various ethics, values, and specific rules of conduct (Carter et al., 2011).
The existence of ethical principles is essential in order for health professionals to be able to
make decisions within an ethical framework. There are three basic ethical principles that
characterise the field of Health Promotion, and have been adopted by the ethical theoretical
background that distinguishes medical science: (Naidoo & Wills, 2000; Weed & McKeown,
2001)

1. Respect for autonomy; respect for the right of individuality and the right of the
individual to determine his/her own life. The limits of an individual's autonomy are set
where actions can harm a third party. The principle of autonomy maintains that
individuals should not act out of fear or pressure in order to make a decision. Health
promotion professionals should help individuals to strengthen their autonomy. This is
also a requirement by the concept of self-empowerment, self-efficacy and self-
knowledge which are basic concepts for health promotion. Many ethical issues arise in
the case of individuals, who are incapable of making decisions for themselves, as in the
case of individuals with specific mental disorders and children, for whom third parties
are therefore called upon to decide. Then the concept of autonomy really becomes more
difficult. People who are involved in health promotion should be able to respect the
right to autonomy, but at the same time work for its development, by building on
awareness since only when the individual is fully aware of their potential and the
options available can make better informed decisions.
2. The principles of benevolence and non-harm. These principles emphasise that any
activity in the context of health promotion, should aim at achieving maximum benefit
and at the same time in preventing and avoiding harm. In the context of public health
and its policies, sometimes the common good prevails over the individual, a fact that is
in line with utilitarian theory, according to which the greatest good should be sought
for the greatest number of individuals. Screening is a classic example of the complex
moral issues that can arise in relation to this principle. Are all checks risk free? Is there

14
 always a cure? What are the psychological consequences in the case of a false positive
finding and respectively what are the consequences and risks of a false negative
finding? Sometimes the intention of health professionals to do good and avoid doing
bad is not always an easy task. In any case, the health professional must inform about
the possible benefits of each activity or practice.
3. The principle of justice. The principle of justice stipulates that all individuals are treated
equally and are considered equal. In the context of health promotion, this principle finds
application in the provision of appropriate services to all individuals, equal
opportunities to access them and treatment of all inequalities. However, it should not
be considered that health promotion can autonomously fill and improve the gap of
social inequalities. However, as part of a coordinated effort and planning, it can make
a significant contribution in this direction.

One of the most common ethical issues in the field of health promotion is the approach taken
by health professionals to the concept of health. When health is reduced to an absolute purpose,
including all aspects of life, then there is a risk of developing a particular philosophy, which is
called healthism. (Doxiadis, 1991; Brown, 2018). Here the concept of health acquires a
dogmatic character, and the health professionals, committed to the ideal framework that they
have formed for health, would impose the changes that they believe in, thus trying to control
the behaviour. This fact, however, counters the basic principles of health promotion, according
to which the individual should develop control over his health through self-empowerment as a
primary option. An important ethical issue may arise when health professionals take it for
granted that all individuals have the same ability to avoid certain health risk factors that are
considered preventable. As a result, when people develop a disease or disorder, they are blamed
or even stigmatised for this weakness and are considered responsible for their state of health.
This attitude towards individuals is called victim blaming. Lastly, an important ethical issue,
is the exclusion of groups from health promotion, which are usually categorised as minorities.
Health promotion should offer everyone equal opportunities to participate, and not just address
the average recipient. When the methodology of health promotion does not meet the

15
expectations, beliefs, preferences, or abilities of the public, then there is a risk of increasing
social inequalities (Raeburn & Beaglehole, 1989).

References
Brown, R.C.H (2018), Resisting Moralisation in Health Promotion. Ethic Theory Moral
Prac 21, 997–1011, https://doi.org/10.1007/s10677-018-9941-3

Carter, S. M., Rychetnik, L., Lloyd, B., Kerridge, I. H., Baur, L., Bauman, A., Hooker, C., &
Zask, A. (2011). Evidence, ethics, and values: a framework for health promotion. American
journal of public health, 101(3), 465–472. https://doi.org/10.2105/AJPH.2010.195545

Dans A., Ng N., Varghese C., Tai ES., Firestone R., Bonita R. (2011). The rise of chronic non-
communicable diseases in southeast Asia: time for action. Lancet, 377:680–9.

Downie R.S, Tannahil C, Tannahil A, (1996), Health Promotion Models and Values. Oxford
Medical Publications.

Doxiades SA. Ethics of health promotion and health education. J Int Bioethique. 1991 Jul-
Sep;2(3):179-86. PMID: 11654899.

Elaine Auld M., Radius S., Galer-Unti R., Hinman J., Gotsch A., Mail P. (2011). Distinguishing
Between Health Education And Health Information Dissemination. Am J Public Health,
101(3): 390–391.

Ewles L, & Simnett I, (2003), Promoting Health, a practical guide. Bailliere Tindall.

Lucas, K. & Lloyd, B. (2005) Health Promotion: Evidence and Experience. Sage (online).
Available at
https://ebookcentral.proquest.com/lib/ljmu/reader.action?docID=354952&ppg=12

Murukutla N, Yan H, Wang S, Negi, N.S., Kotov, A., Mullin, S. & Goodchild, M. (2018) Cost-
effectiveness of a smokeless tobacco control mass media campaign in India. Tobacco
Control 2018;27:547-551(online). Available at:
https://tobaccocontrol.bmj.com/content/27/5/547

16
Naidoo J, & Wills J, (2000), Health Promotion: foundations for Practice, Bailliere Tindall.

Naidoo, J. & Wills, J. (2007). Models and approaches to health promotion. in Health
promotion: Foundations for practice. Naidoo, J. and Wills, J., Bailliere Tindall / Royal College
of Nursing.

Prochaska JO & Velicer WF (1997), The Transtheoretical Model of Health Behavior

Change. American Journal of Health Promotion ;12(1):38-48. doi:10.4278/0890-1171-12.1.38

Raeburn, J. & Beaglehole, R. (1989), Health promotion: can it redress the health effects of
social disadvantage? Community Health Studies, 13: 289-293. https://doi.org/10.1111/j.1753-
6405.1989.tb00208.x

Tones K, & Tilford S, (1994), Health education, effectiveness, efficiency, equity. London,
Chapman and Hall.

Weed D.L & McKewon R.E, (2001), Ethics in epidemiology and public health I. Technical
term, Journal of Epidemiology and Community Health, 55(12): 855-857.

17