HEALTH PROMOTION

What is Health Promotion all

about?
What is Health Promotion all
about?
 It is the process of enabling people to
increase control over and improve their
health. (Ottawa H.P. Charter).
 It is a process which empowers families and
communities to improve their quality of life,
and achieve and maintain health and
wellness.
 It emphasizes not only prevention of disease
but the promotion of positive good health.
 What is Health Promotion all
about?
 It is a positive concept emphasizing personal,
social, political and institutional resources, as
well as physical capacities.
 Health promotion is any combination of health,
education, economic, political, spiritual or
organizational initiative designed to bring about
positive attitudinal, behavioral, social or
environmental changes conducive to improving
the health of populations.
 What is Health Promotion all
about?
 Health promotion is directed towards action on the
determinants or causes of health
 Health promotion, therefore, requires a close co-
operation of sectors beyond health services, reflecting
the diversity of conditions which influence health.
 Government at both local and national levels has a
unique responsibility to act appropriately and in a
timely way to ensure that the ‘total’ environment,
which is beyond the control of individuals and groups,
is conducive to health.
 Definitions of health
promotion
 "Health promotion is the science and art of helping people
change their lifestyle to move toward a state of optimal health. 
Optimal health is defined as a balance of physical, emotional,
social, spiritual, and intellectual health.  Lifestyle change can be
facilitated through a combination of efforts to enhance
awareness, change behavior and create environments that
support good health practices.  Of the three, supportive
environments will probably have the greatest impact in
producing lasting change".  (American Journal of Health
Promotion, 1989,3,3,5)
PRINCIPLES OF HEALTH
PROMOTION
The key principles of health
promotion as determined by WHO
are as follows:
Health promotion involves the
population as a whole in the
context of their everyday life,
rather than focusing on people at
risk from specific diseases.

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PRINCIPLES OF HEALTH
PROMOTION
Health promotion is directed
towards action on the determinants or
cause of health. This requires a close
co-operation between sectors beyond
health care reflecting the diversity of
conditions which influence health.

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PRINCIPLES OF HEALTH
PROMOTION
Health promotion aims particularly
at effective and concrete public
participation. This requires the further
development of problem-defining and
decision-making life skills, both
individually and collectively, and the
promotion of effective participation
mechanisms.

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PRINCIPLES OF HEALTH
PROMOTION
Health promotion combines diverse,
but complementary methods or
approaches including communication,
education, legislation, fiscal measures,
organisational change, community change,
community development and spontaneous
local activities against health hazards.

9
PRINCIPLES OF HEALTH
PROMOTION
Health promotion is primarily a
societal and political venture and
not medical service, although health
professionals have an important role
in advocating and enabling health
promotion.

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Health Promotion includes …
 Promoting healthy lifestyles.
 Getting people involved in their own
health care.
 Creating an environment that makes it
possible to live a healthy life.
 Recognition of lifestyle diseases as
major causes of illness and death.
 Strengthening community participation.
Examples of preventable health
problems related to lifestyle
 Chronic non-communicable diseases such as
diabetes and hypertension. These are major
causes of illness and death. They are related
to…
 Overweight and obesity.
 Unhealthy diet.
 Insufficient physical activity.

 HIV/AIDS is related to unsafe sexual lifestyle,

and causes many deaths.
 Intersectoral approach
Health Promotion brings together many sectors
to work towards the achievement and
maintenance of health and wellness.
 The Health sector alone cannot achieve a healthy
society.
 All sectors, both government and non-government,
need to work together.
 Health Promotion can provide the link between the
various sectors.
 Within Health the various disciplines also need to
work together towards wellness.
Some non-health sectors with an
input into Health Promotion…
 Education/ schools
 Agriculture
 Community Services
 Sport
 Media
 Non-Governmental Organizations (NGO’s)
 Community groups
 Youth
 Private sector
Health sectors with an input into
Health Promotion
 Environmental Health
 Nutrition
 Community nursing
 Mental Health
 Dental
 Epidemiology
 Hospital (secondary) care
 School of Nursing
 Occupational therapy
Some other sectors which are
important
 Legal
 Public Works
 Housing
 Water Authority
 Traditionalists
 Christian Council
 Alternative medicine
IMPORTANT AREAS FOR CONSIDERATION IN
HEALTH PROMOTION

Building a Creating supportive

healthy public environments
policy

Strengthening
community
action

Developing Reorientating
personal skills health services

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Formulating healthy public
policy
 Promotes healthy policies in all sectors , eg
healthy workplaces, schools, homes,
buildings, villages and communities.
 Health aspect should be thought of and
included in the policies of the various sectors.
 Health Policies should also emphasize the
prevention and promotion.
Reorienting health services
Since lifestyle is linked to many of today’s health
problems, prevention and promotion should
decrease the burden on secondary (curative)
health care.
 Greater emphasis and resources placed on health
promotion and primary health care.
 Less emphasis on purchase of high tech equipment
for secondary health care.
 Equity in health care.
Empowering communities to
achieve well-being
 Involvement of the community in health
decisions, a multisectoral and participatory
approach.
 Provide communities with the information and
tools to take actions to improve health and
well-being.
Creating supportive environments
 Healthy physical, social and economic
environment.
 All development activities should aim for a
healthy environment – healthy buildings,
roads, workplaces, homes, surroundings and
schools.
Developing /increasing personal
health skills
 Information and education for personal and
family health.
 Take account of values, beliefs and customs
of the community.
 Continuous process at all stages of life.
 Guided and supported in developing skills
(not imposed on them).
 Build on existing knowledge and attitudes.
Building alliances with special
emphasis on the media
 Media key players, influence on health of
people.
 Partnership with media ensures their
collaboration and that correct information is
passed on.
 Free flow of information both ways, on
matters vital to health.
Theories of Health Behaviour

Health Psychology: understanding

how/why people behave in a
certain way and how to help them
change
 Attribution theory

 People attempt to provide a

causal explanation for events in
their world particularly if those
events are unexpected and
have personal relevance
(Heider, 1958).
 Hence people will generally
seek a causal explanation for an
illness, particularly one that is
serious.
 Proof
 Taylor et al. (1984) interviewed a sample of
women who had been treated for breast
cancer.
 95% of the women had a causal explanation
for their cancer.
 These causes were classified as stress (41%),
specific carcinogen (32%), heredity (26%), diet
(17%), blow to breast (10%) and other (28%).
Women’s causal explanation
for breast cancer
 Attribution theory
 Asked the women who or what they considered
responsible for the disease
 41% of the women blamed themselves,
 10% blamed another person,
 28% blamed the environment and
 49% blamed chance.
 The patients were also asked whether they felt any
control over their cancer and they found 56% felt they
had some control.
Women’s attribution of
responsibility for cancer
 Attribution Theory
 Weiner et al. (1972) suggested that we can
classify attributional dimensions along three
dimensions:
 Locus: the extent to which the cause is localized
inside or outside the person.
 Controllability: the extent to which the person has
control over the cause.
 Stability: the extent to which the cause is stable or
changeable.
 Health Locus of control
 Health locus of control, like attribution
theory, also emphasises attributions for
causality and control.
 Health Locus of control
 Wallston and Wallston (1982) developed a
measure of the health locus of control,
 which evaluates whether individuals regard
their health as controllable by them or not
controllable by them or
 they believe their health is under the control
of powerful others.
 Health Locus of control
 There are several problems with the
concept of a health locus of control:
 Is health locus of control a fixed trait or a
transient state?
 Is it possible to be both external and internal?
 Going to the doctor could be seen as external
(the doctor is a powerful other) or internal (I
am looking after my health).
 Unrealistic optimism
 Unrealistic optimism focuses
on perceptions of
susceptibility and risk.
 Weinstein (1984) suggested that
one of the reasons why people
continued to practice unhealthy
behaviours is due to inaccurate
perceptions of risk and
susceptibility - their unrealistic
optimism.
Unrealistic optimism
 He asked subjects to examine a list of
health problems and displayed what
"compared to other people of your age
and sex, are your chances of getting
the problem greater than, about the
same, or less than theirs?" Most
subjects believed they were less likely
to get the health problem.
Unrealistic optimism
 Weinstein (1987) described four
cognitive factors that contribute to
unrealistic optimism:
 1. Lack of personal experience with the
problem
 2. The belief that the problem is
preventable by individual action
Unrealistic optimism
 3. The belief that if the problem has not
yet appeared, it will not appear in the
future
 4. The belief that the problem is
infrequent.
The theories/models of
behaviour change
The transtheoretical model of behaviour
change (stages of change model)
 The model states that people go
through different stages to change
their behaviours
 Know about these stages and learn
to go along with them
The transtheoretical model of behaviour
change (stages of change model)
 1. Precontemplation: not intending to make
any changes
 2. Contemplation: considering a change
 3. Preparation: making small changes
 4. Action: actively engaging in a new
behaviour
 5. Maintenance: sustaining change over
time
The transtheoretical model of behaviour
change (stages of change model)
 Individuals would go through these stages in
order but might also go back to earlier stages.
 People in the later stages, e.g. maintenance,
would tend to focus on the benefits (I feel
healthier after giving up smoking or going to
the gym),
 People in the earlier stages tend to focus on
the costs (I will be at a social disadvantage if I
give up smoking).
The transtheoretical model of
behaviour change (stages of
change model)
 A relationship has been found between
level of education and the stage of
change reached when contemplating
taking regular exercise.
The transtheoretical model of behaviour
change (stages of change model)
 Those people with lower levels of
education tended to be at an earlier stage
of change (Booth et al. 1993), and
therefore it could be argued that the
model could be improved by taking
account educational attainment in order to
help predict the length of time a person is
likely to remain at the earlier stages.
 Health belief model
 Support for individual components of the
model.
 Norman and Fitter (1989) examined health
behaviour screening (for example breast cervical
cancer) and found that perceived barriers (the
costs of attending) were the greatest predictors
of whether a person attended the clinic.
 Hence dealing with barriers important
Health belief model
 Several studies have examined breast
self-examination (BSE) behaviour and
report that barriers (Lashley 1987;
Wyper 1990) and perceived
susceptibility (the likelihood of having
the illness) (Wyper 1990) are the best
predictors of healthy behaviour.
Health belief model
 The role of giving information as a cue
to action has been researched.
Information in the form of fear-arousing
warnings may change attitudes and
health behaviour in such areas as
dental health, safe driving and smoking
(e.g. Sutton 1982; Sutton and Hallett
1989).
Health belief model
 Giving information about the bad
effects of smoking is also effective in
preventing smoking and in getting
people to give up (e.g. Sutton 1982;
Flay 1985). Several studies report a
significant relationship between people
knowing about an illness and their
taking precautions.
Health belief model
 Rimer et al. (1991) report that knowledge
about breast cancer is related to having
regular mammograms. Several studies
have also indicated a positive correlation
between knowledge about BSE (Breast
Self-examination) and breast cancer and
performing BSE (Alagna and Reddy 1984;
Lashley 1987; Champion 1990).
Evidence Against the HBM
 Janz and Becker (1984) found that healthy
behavioural intentions are related to low
perceived seriousness - not high as predicted
(e.g. healthy adult having a flu injection) - and
several studies have suggested an association
between low susceptibility (not high) and
healthy behaviour (e.g. many students recently
have agreed to be inoculated against
meningitis) (Becker et al. 1975; Langlie 1977).
Evidence Against the HBM
 Hill et al. (1985) applied the HBM to
cervical cancer, to examine which
factors predicted cervical screening
behaviour. Their results suggested that
benefits and perceived seriousness
were not related.
Evidence Against the HBM
 Janz and Becker (1984) carried out a
study using the HBM and found the
best predictors of health behaviour to
be perceived barriers and perceived
susceptibility to illness.
Evidence Against the HBM
 However, Becker and Rosenstock (1984), in
a review of 19 studies using a meta-
analysis that included measures of the HBM
to predict compliance, calculated that the
best predictors of compliance are the costs
and benefits and the perceived seriousness.
So there is lack of agreement over what
really does help to predict health behaviour.
Criticisms of the HBM
 Is health behaviour that rational? (Is tooth-
brushing really determined by weighing up
the pros and cons?).
 Its emphasis on the individual (HBM
ignores social and economic factors)
 The measurement of each component
 The absence of a role for emotional factors
such as fear and denial.
Criticisms of the HBM
 It has been suggested that alternative
factors may predict health behaviour,
such as outcome expectancy (whether the
person feels they will be healthier as a
result of their behaviour) and self-efficacy
(the person’s belief in their ability to carry
out preventative behaviour) (Seydel et al.
1990; Schwarzer 1992).
The revised HBM
 Becker and Rosenstock (1987) have revised
the HBM and have described their new
model as consisting of the following factors:
 the existence of sufficient motivation;
 the belief that one is susceptible or vulnerable to a
serious problem;
 and the belief that change following a health
recommendation would be beneficial to the
individual at a level of acceptable cost.
Protection motivation
theory
Protection motivation
theory
 Rogers (1975, 1983, 1985) developed
protection motivation theory (PMT)
which expanded the HBM to include
additional factors.
 Components of the PMT
 Health-related behaviours are a product
of five components:
Protection motivation
theory
 Coping Appraisal
 self-efficacy (e.g. 'I am confident that I can
change my diet');
 Response effectiveness (e.g. 'changing my diet
would improve my health');
 Threat Appraisal
 Severity (e.g. 'bowel cancer is a serious illness');
 Vulnerability (e.g. 'my chances of getting bowel
cancer are high').
 Fear
Protection motivation
theory
 According to the PMT, there are two sources
of information:
 1.      environmental (e.g. verbal persuasion,
observational learning) and
 2.      intrapersonal (e.g. prior experience).
 This information elicits either an 'adaptive'
coping response (i.e. the intention to improve
one's health) or a 'maladaptive' coping
response (e.g. avoidance, denial).
Support for the PMT

 Rippetoe and Rogers (1987) gave

women information about breast cancer
and examined the effect of this
information on the components of the
PMT and their relationship to the
women's intentions to practise breast
self-examination (BSE).
Support for the PMT

 The results showed that the best

predictors of intentions to practise BSE
were response effectiveness (believing
that BSE would detect the early signs of
cancer), severity (believing that Breast
cancer is dangerous and difficult to
treat in it's advanced stages) and self-
efficacy (belief in one's ability to carry
out BSE effectively).
Support for the PMT

 In a further study, the effects of persuasive

appeals for increasing exercise on intentions
to exercise were evaluated using the
components of the PMT. The results showed
that vulnerability (ill health would result from
lack of exercise) and self-efficacy (believing in
one's ability to exercise effectively) predicted
exercise intentions but that none of the
variables were related to self-reports of actual
behaviour.
Support for the PMT

 In a further study, Beck and Lund (1981)

manipulated dental students' beliefs about
tooth decay using persuasive communication.
Their results showed that the information
increased fear and that severity (tooth decay
has disastrous consequences) and self-
efficacy (I can do something about it) were
related to behavioural intentions (flossing and
brushing regularly especially after eating).
Criticisms of the PMT

 The PMT has been less widely criticized than the

HBM; however, many of the criticisms of the
HBM also relate to the PMT. For example, the
PMT assumes that individuals are rational
information processors (although it does include
an element of irrationality in its fear
component), it does not account for habitual
behaviours, such as brushing teeth, nor does it
include a role for social (what others do) and
environmental factors (eg opportunities to
exercise or eat properly at work).
Criticisms of the PMT

 Schwarzer (1992) has also criticized the

PMT for not tackling how attitudes
might change (a problem with the HBM
as well).
Social cognition models

 Social cognition theory was developed by Bandura

(1977, 1986) and suggests that expectancies,
incentives and social cognitions govern behaviour.
Expectancies include:
 Situation outcome expectancies: the expectancy
that a behaviour may be dangerous (e.g. 'smoking
can cause lung cancer').
 Outcome expectancies: the expectancy that
behaviour can reduce the harm to health (e.g.
'stopping smoking can reduce the chances of lung
cancer').
Social cognition models

 Self-efficacy expectancies: the expectancy that

the individual is capable of carrying out the
desired behaviour (e.g. 'I can stop smoking if I
want to').
 The concept of incentives suggests that
behaviour is governed by its consequences. For
example, smoking behaviour may be reinforced
by the experience of reduced anxiety, whereas
a feeling of reassurance may reinforce having a
cervical smear after a negative result.
Social cognition models

 Social cognitions involve normative beliefs

(e.g. 'people who are important to me want
me to stop smoking').
 Parents have a strong influence over the
health behaviours of children of the same sex
with regard to Exercise, Smoking, Drinking,
Eating and Sleep (Wickrama, Conger, Wallace
and Elder, Journal of Health and Social
Behaviour, 1999).
Social cognition models
Social cognition models
Theory of planned behaviour
Theory of planned behaviour
 The TPB emphasizes behavioural intentions as
the outcome of a combination of several
beliefs.
 Intentions - 'plans of action in pursuit of
behavioural goals' (Ajzen and Madden 1986)
and are a result of the following beliefs:
  
 1.      Attitude towards a behaviour - positive or
negative -(e.g. 'exercising is fun and will
improve my health').
Theory of planned behaviour
 2.        Subjective norm - social pressure
and motivation (e.g. 'people who are
important to me will approve if I lose
weight and I want their approval').
 3.        Perceived behavioural control -
self-efficacy and possible barriers
Support for the TPB

 Povey et al (2000) studied the

intentions of people to eat five portions
of fruit and vegetables per day or to
follow a low-fat diet. The TPB was good
at predicting intentions but not
behaviour. Self-efficacy was found to be
a better predictor of behaviour.
Support for the TPB

 Rutter (2000) studied women and

whether or not they attended two
breast-screening sessions separated by
three years. Intention and first-time
attendance was successfully predicted
by the TPB. Attendance at the first
session, however, was the best
predictor of whether the woman
attended three years later.
Support for the TPB

 Brubaker and Wickersham (1990)

examined the role of the theory's
different components in predicting
testicular self-examination and reported
that attitude towards the behaviour,
subjective norm and behavioural control
(measured as self-efficacy) correlated
with the intention to perform the
behaviour.
Support for the TPB

 TPB in relation to weight loss (Schifter

and Ajzen 1985). The results showed
that weight loss was predicted by the
components of the model; in particular,
goal attainment (weight loss) was
linked to perceived behavioural control.
Evaluation of the TPB
Good
 Degree of irrationality
 Considers Social and Environmental factors
 Considers past behaviour within the
measure of perceived behavioural control.
Bad
 Schwarzer (1992) Ajzen does not describe
either the order of the different beliefs or
says what causes what (causality).
The health action process
approach
The health action process
approach
 The health action process approach (HAPA)
was developed by Schwarzer in 1992.
 1.     it includes a temporal element in the
understanding of beliefs and behaviour.
 2.     it emphasized the importance of self
efficacy
 3.      distinction between a
decision-making/motivational stage and an
action maintenance stage.
Components of the HAPA

 According to the HAPA, the motivation stage is

made up of the following components:
 self-efficacy (e.g. 'I am confident that I can stop
smoking');
 outcome expectancies (e.g. 'stopping smoking will
improve my health'), and a subset of social outcome
expectancies (e.g. 'other people want me to stop
smoking and if I stop smoking I will gain their
approval');
 threat appraisal, which is composed of beliefs about
the severity of an illness and perceptions of individual
vulnerability.
Components of the HAPA

 The action stage is composed of:

 A cognitive factor made up of action plans (e.g. 'if
offered a cigarette when I am trying not to smoke
I will imagine what the tar would do to my lungs')
and action control (e.g. 'I can survive being
offered a cigarette by reminding myself that I am
a non-smoker').
 The situational factor consists of social support
(e.g. the existence of friends who encourage non-
smoking) and the absence of situational barriers
(e.g. financial support to join an exercise club).
Support for the HAPA

 Schwarzer (1992) claimed that self-efficacy

was consistently the best predictor of
behavioural intentions and behaviour change
for a variety of behaviours, including
frequency of flossing, effective use of
contraception self-examination, drug addicts'
intentions to use clean needles, intentions to
quit smoking, and intentions to adhere to
weight loss programmes and exercise (e.g.
Beck and Lund 1981; Seydal et al. 1990).
Criticisms of the HAPA

 Too rational - emotion is neglected

 The social and environmental influences are
not considered as directly affecting behaviour,
but rather as cognitions·
 Do these cognitive states exist or are they
simply created cognitive theorists?
 The model attempts to combine components
of the health belief model, the trans-
theoretical model of change and the theory of
planned behaviour.
Non-Rational processes

 The defence mechanism of Denial

 Cigarette smokers etc
Lay theories about health
 Communication between health
professional and patient would be
redundant if the patient held beliefs
about their health that were in conflict
with those held by the professional.
Lay theories about health
 Pill and Stott (1982) reported that working-
class mothers were more likely to see illness
as uncontrollable.
 In a recent study, Graham (1987) reported
that although women who smoke are aware
of all the health risks of smoking, they report
that smoking is necessary to their well-being
and an essential means for coping with
stress.
Lay theories about health
 Blaxter (1990) analysed the definitions of health
provided by over 9000 British adults in the health
and lifestyles survey. She classified the responses
into nine categories:
           Health as not-ill: the absence of physical
symptoms.
           Health despite disease.
           Health as reserve: the presence of personal
resources.
           Health as behaviour: the extent of healthy
behaviour         
The end