MODELS OF

HEALTH 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
PARADIGMS OF HEALTH PROMOTION (CAPLAN
AND HOLLAND - 1990)
Radical
RADICAL HUMANIST Nature of RADICAL STRUCTURLIST
change
• Holistic view of health society • Health reflects structural
inequalities
• De-professionalization
• Need to challenge inequity and
• Self-help networks
radically transform society.

Subjective Objective
Nature of
knowledge
HUMANIST
TRADITIONAL
• Holistic view of health
• Health = absence of disease
• Aims to improve understanding
and development of self • Aim is to change behaviour

• Client-led • Expert-led
Social
regulation
MODEL OF HEALTH PROMOTION 2: HEALTH
PROMOTION METHODS USING BEATTIE’S
TYPOLOGY (BEATTIE – 1991)
MODE OF INTERVENTION
Advice Legislation

Education
Authoritarian Policy making and
implementation
Behaviour change
Health surveillance
Mass media campaign

Individual Collective
Focus of
intervention
Counselling
Lobbying
Education
Action research
Group work
Skills sharing and training
Group work
Community development
Negotiated
MODEL OF HEALTH PROMOTION 3: A TYPOLOGY
OF HEALTH PROMOTION (FRENCH – 1990)

DISEASE
MANAGEMENT
• Curative services
• Management services HEALTH
DISEASE EDUCATION
• Caring services
PREVENTION • Agenda setting
• Preventive services • Empowerment and
• Medical services support
• Behaviour change • Information
POLITICS OF HEALTH
• Social action
•Policy development
• Economic and fiscal
policy
 MODEL OF HEALTH PROMOTION 4: TANNAHILL’S
MODEL OF HEALTH PROMOTION (DOWNIE et al – 1990)

5 6. Positive health
1. Preventive services, Health education
e.g. immunization, protection, e.g.
cervical screening, workplace
2 7
hypertension case smoking policy.
1 4 6
finding, Health
developmental Prevention 3 protection 7. Health education
surveillance, use of aimed at positive
nicotine chewing gum health protection,
to aid smoking
3. Preventive health protection, e.g. e.g. lobbying for
cessation. a ban on tobacco
fluoridation of water.
advertising.
2. Preventive health 4. Health education for preventive
education, e.g. health protection, e.g. lobbying
smoking cessation for seat belt legislation.
advice and 5. Positive health education, e.g
information. lifeskills with young people.
 MODEL OF HEALTH PROMOTION 5: THE
CONTRIBUTION OF EDUCATION TO HEALTH
PROMOTION (TONES et al – 1990)

Public pressure Healthy public Lobbying

policy
Advocacy
Mediation
Healthy social
and physical
Empowered Healthy promoting
environment
participating organisation
community
HEALTH Healthy
services
Critical
Agenda Healthy Professional
consciousness
setting choices education
raising

Education for health

 APPROACHES
TO HEALTH PROMOTION
 Approaches in Health Promotion:
the example of healthy eating
Worker/client
Approach Aims Methods
relationship

Medical To identify Primary Expert-led.

those at risk health care
Passive,
from disease. consultation.
conforming
e.g. client.
measurement
of body mass.
 Approaches in Health Promotion:
the example of healthy eating
Worker/client
Approach Aims Methods
relationship

Behavior To encourage Persuasion Expert-led.

change individuals to through one-
to-one advice, Dependent
take client.
responsibility information,
mass Victim
for their own
campaigns, blaming
health and
e.g. ‘Look ideology.
choose
After Your
healthier Heart’ dietary
lifestyles. messages.
 Approaches in Health Promotion:
the example of healthy eating
Worker/client
Approach Aims Methods
relationship
Educational To increase Information. May be expert
knowledge led.
Exploration of
and skills attitudes May also
about healthy through small involve client
lifestyles. group work. negotiation of
issues for
Development discussion.
of skills, e.g.
women’s
health group.
 Approaches in Health Promotion:
the example of healthy eating
Worker/client
Approach Aims Methods
relationship
Empowerment To work with Advocacy Health
client or promoter is
Negotiation
communities facilitator,
to meet their Networking client becomes
empowered.
perceived Facilitation
needs. e.g. food
co-op, fat
women’s
group.
 Approaches in Health Promotion:
the example of healthy eating
Worker/client
Approach Aims Methods
relationship
Social change To address Development of Entails social
organizational
inequalities in policy, e.g. hospital
regulation and
health based catering policy is top-down.
on class, race, Public health
legislation, e.g.
gender, food labelling.
geography.
Fiscal controls, e.g.
subsidy to farmers
to produce lean
meat.
 Religion and Health - 3
Quran & Ahadith

Five Pillars Elements Islamic

of Islam of Faith Jurisprudence

Salutogenic Sense of Predisposing &

Mechanism coherence Enabling factors

Behavior Figure 1: Pathways

of ‘Islamic Health
Healthy Lifestyle Theory’
Putting Islamic Concepts Into Practice
for Health Promotion 1

Plan Do

Act Check
Putting Islamic Concepts Into Practice
for Health Promotion 2

• Precede-proceed model.
• Intervention mapping.
• A five-stage model.
 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
 Putting Islamic Concepts Into Practice
for Health Promotion 2.2
Intervention mapping.

STEP 1: Proximal program objective matrices

STEP 2: Theory –based methods and practical strategies
STEP 3: Program plan
STEP 4: Adoption and implementation plan
STEP 5: Evaluation plan
 Putting Islamic Concepts Into Practice
for Health Promotion 2.3
A five-stage model (Bracht et al. 1999)

1. Community
analysis

5. Dissemination
- reassessment 2. Design
- initiation
COMMUNITY
ORGANIZATION
STAGES
4. Maintenance
- consolidation

3. Implementation
Putting Islamic Concepts Into Practice
for Health Promotion 3.1
An illustration using the five-stage model (Bracht et al. 1999)

1. Community analysis.
 Putting Islamic Concepts Into Practice
for Health Promotion 3.2
An illustration using the five-stage model (Bracht et al. 1999)

2. Design - initiation.
 Putting Islamic Concepts Into
Practice for Health Promotion 3.3
An illustration using the five-stage model (Bracht et al. 1999)

3. Implementation.
Putting Islamic Concepts Into Practice
for Health Promotion 3.4
An illustration using the five-stage model (Bracht et al. 1999)

4. Maintenance - consolidation.
Putting Islamic Concepts Into Practice
for Health Promotion 3.5
An illustration using the five-stage model (Bracht et al. 1999)

5. Dissemination - reassessment.
Promoting Healthy Behavior
 Behavior and Global 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)

• Physical good health eludes billions of people

• Death and disease from preventable causes
remain high
• Behavior is a key factor in determining health
 Ten Leading Risk Factors
for Preventable Disease
• Maternal and child • High cholesterol
underweight • Indoor smoke from
• Unsafe sex solid fuels
• High blood pressure • Iron deficiency
• Tobacco • High body mass index
• Alcohol or overweight
• Unsafe water, poor
sanitation, & hygiene

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
Injuries

Communicable 9%
diseases, Noncommunicable
maternal and 31% diseases
perinatal 60%
conditions, and
nutritional
deficiencies

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 structures
E Public Policy: local policies related to healthy
practices
Source: 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

Maintenance Contemplation

Action Decision
 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 Change
Organizational Stage Organizational
Theory Development Theory
Define problem

Organizational structures
Identify solutions

Initiate action

Allocate resources Worker behavior and motivation

Implement

Institutionalize
 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.