Theories and Approaches in Health Promotion - PDF by csgirla

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									Theories and Approaches in
    Health Promotion
      Theories and Approaches in
          Health Promotion
    Three major health promotion approaches will be
•     the behaviour change approach,
•     the self-empowerment approach and
•     the ‘collective action’ or community development

•     Health promotion interventions informed by each
    approach will be described and critically evaluated.
         Three approaches

These three approaches pursue different
goals, utilize different means to achieve
their goals and propose different criteria for
their evaluation. However, they all aim to
promote good health and to prevent or
reduce the effects of ill health
Behaviour change approach

 Objective: to bring about changes in individual
 behaviour through changes in individuals’
 Process: provision of information related to health
 risks and hazards.
 Aims: to increase individual’s knowledge about
 the causes of health and illness.
 Assumption: humans are rational decision-makers
 whose cognitions inform their actions.
        Behaviour Change
The goal of this approach is to bring about changes in
individual behaviour through changes in the individual’s
cognitions. The approach is based upon the assumption
that humans are rational decision-makers and therefore
relies heavily upon the provision of information about risks
and health hazards through the mass media as well as
leaflets and posters. Information is presented as factual and
attributed to an expert source. Here, health promotion is
really synonymous with health education that aims to
increase individuals’ knowledge about the causes of health
and illness. This approach is also known as the
‘information-giving model’ (Aggleton, 1989)
Social cognition models (SCMs)
 These have been researched in a wide range of
 preventive health behaviours such as vaccination
 uptake, breast self-examination and contraceptive
 use. SCMs aim to predict the performance of
 behaviours and, by implication, to provide
 guidance as to how to facilitate their uptake by
 manipulating relevant variables (such as beliefs,
 attitudes and perceptions). It is suggested that
 there is a close relationship between people’s
 beliefs, attitudes and intentions to act in particular
 ways. Consequently, by bringing about changes in
 beliefs it is hoped to bring about changes in
    Example: smoking and the
    Health Belief Model (HBM;
          Becker, 1974).
Smokers deciding whether or not to give up smoking
  would be expected to consider:

•      how susceptible they are to lung cancer and
    other smoking-related conditions
•      how serious these conditions are
•   the extent and value of the benefits of giving up
•      the potential negative consequences of giving
    up smoking
the role of cues to action, internal (e.g. a
symptom such as a smoker’s cough) and
external (e.g. information, advice or
meeting someone with lung cancer)

health motivation, i.e. the importance of
health to the individual.
         Health Belief Model
The Health Belief Model (HBM) is a
psychological model that attempts to explain
and predict health behaviors. This is done by
focusing on the attitudes and beliefs of
individuals. The HBM was first developed in
the 1950s by social psychologists Hochbaum,
Rosenstock and Kegels working in the U.S.
Public Health Services. The model was
developed in response to the failure of a free
tuberculosis (TB) health screening program.
Since then, the HBM has been adapted to
explore a variety of long- and short-term
health behaviors, including sexual risk
behaviors and the transmission of HIV/AIDS.
            Health belief model

  The HBM is based on the idea that a person will take a
  health-related action (i.e., use condoms) if that person:

• feels that a negative health condition (i.e., HIV) can be
• has a positive expectation that by taking a
  recommended action, he/she will avoid a negative
  health condition (i.e., using condoms will be effective at
  preventing HIV), and
• believes that he/she can successfully take a
  recommended health action (i.e., he/she can use
  condoms comfortably and with confidence).
 The theory of reasoned action
(TRA) and the theory of planned
       behaviour (TPB)
Propose that behaviour is informed by attitudes
towards the behaviour as well as subjective norms
about the behaviour, that is what significant others
think one should do. These variables (and in the
case of the TPB an additional variable: perceived
control over the behaviour) combine to generate
an intention to behave in a particular way, which
is then used to predict actual behaviour.
      Example: birth control
A woman’s belief that birth control pills are a
potential health risk and her belief that her friends
and relatives would not approve of her taking such
a risk are thought to generate a negative attitude
towards taking birth control pills, as well as social
pressure not to take them; thus giving rise to the
intention to refrain from the use of birth control
pills and, hopefully, to consider other forms of

1 SCMs are only concerned with cognitively
mediated behaviours.
2 SCMs do not take into account the direct
effect of impulse and/or emotion.
3 SCMs assume that the same variables inform
different health behaviours.
4 SCMs assume that the same variables are
relevant for diverse groups of people.
5 SCMs focus exclusively upon mental
representations of the social world and do not take
into account the direct effects of material, physical
and social factors.
6 SCMs do not address the issue of joint
7 SCMs rely upon a narrow definition of
‘behaviour’ that isolates an activity from the
context that gives it its meaning.
Criticisms of the behaviour
      change approach
unable to target the major socio-economic causes
of ill health
operates ‘top-down’- recommendations can be
incompatible with community norms, values and
assumes that there is a direct link between
knowledge, attitudes and behaviour
assumes homogeneity among the receivers of
health promotion messages
Objective: to empower individuals to make
healthy choices.
Process: participatory learning techniques.
Aims: to increase control over one’s
physical, social and internal environments.
Assumption: power is a universal resource
that can be mobilized by every individual.
The goal of this approach to health promotion is to
empower individual people to make healthy
choices. Self-empowerment can be defined as the
process by which groups and individuals increase
their control over their physical, social and
internal environments. In order to facilitate self-
empowerment, participatory learning techniques
allow people to examine their own values and
beliefs and explore the extent to which factors
such as past socialization as well as social location
affect the choices they make (Homans and
Aggleton, 1988).
The self-empowerment paradigm, with its
emphasis upon self-awareness and skills, resonates
with what Stroebe and Stroebe (1995) refer to as
the ‘therapy model’ of health promotion that
deploys a wide range of psychological techniques
such as cognitive restructuring, skills training and
self-conditioning in order to help individuals act
upon their intentions to adopt health behaviours.
However, the self-empowerment approach relies
upon the individual person’s inherent capacity to
act rationally more than the therapy model does.
    What is ‘empowerment’?
“to enhance the possibilities for people to control
their own lives. If this is our aim then we will
necessarily find ourselves questioning both our
public policy and our role relationship to
dependent people ... Empowerment implies that
many competences are already present or at least
possible, given niches and opportunities.
Prevention implies experts fixing the independent
variables to make the dependent variables come
out right. Empowerment implies that what you see
as poor functioning is a result of social structure
and lack of resources that make it impossible for
the existing competencies to operate…
      What is ‘empowerment’?
…It implies that in those cases where
 competences need to be learned, they are
 best learned in a context of living life rather
 than in artificial programs where everyone
 including the person learning, knows that it
 is really the expert in charge”.
  (Rappaport, 1981, pp. 12–13)
 Self-empowerment &
Participatory Learning

Group work
Problem solving
Client-centred counselling
Assertiveness training
Social skills training
Educational drama
  Criticisms of the self-
 empowerment approach
it is assumed that rational choices are
healthy choices

strong reliance upon stimulation

inadequate concept of power
   Collective action or
 community development
Objective: to improve health by addressing socio-
economic and environmental causes of ill health.
Process: individuals organize and act collectively
in order to change their physical and social
Aims: to modify social, economic and physical
structures that generate ill health.
Assumption: communities of individuals share
interests that allows them to act collectively.
     Collective Action or
   Community Development
Ais: to improve health by addressing socioeconomic and
environmental causes of ill health within the community.
Recognizes the close relationship between individual
health and its social and material contexts, which
consequently become the target for change.
Individuals act collectively in order to change their
environment rather than themselves.
Acts at the interface between the environmental and the
behavioural approaches to health promotion
Concerned with the ways in which collectivities can
actively intervene to change their physical and social
The psychologist serves as an agent of change.
   The community as a health
      promotion resource
It is now quite obvious that for many
  people their network of friends,
  neighbours, church relationships, and
  so on, provide not only support, but
  genuine niches and opportunities for
  personal development (Julian
  Rappaport, 1981, p. 19)
Is collective action different from
It could be argued that self-empowerment is part of a
social action process that culminates in the ability to
take collective action. Therefore, a separation of the
self-empowerment and collective action approaches
may seem somewhat artificial. However, self-
empowerment interventions typically limit
themselves to the development of interpersonal skills
in narrow settings and are therefore unlikely to
constitute more than simply a first stage in a
community empowerment process. Furthermore, self-
empowerment can be a consequence rather than a
precondition of collective action.
      Critical consciousness
The collective action approach has been
 influenced by Freire’s (1993) idea of
 critical consciousness in which the
 community comes to recognize the way in
 which social and economic conditions help
 to restrict health and wellness and how
 these conditions can be transgressed by
 political action.
             Social capital
Another concept relevant to this approach is that
of social capital, referring to the community’s
ability to support empowerment through
participation of local organizations and networks.
Putnam (2000) discusses two kinds of social
capital, bonding social capital which refers to
within-group social capital and bridging social
capital which is concerned with linking with
outside bodies with the power and resources to
enable mutually interesting benefits to accrue.
  The WHO’s Healthy Cities
Attempts to combine a community focus with an
acknowledgement of the need to challenge pervasive
inequalities in society. There are over 1000 healthy cities
in Europe and just under 50 WHO Healthy Cities. Any city
can become a healthy city, provided it has a commitment
to health and a process and structure to achieve it. A WHO
Healthy City is part of a network of advanced healthy
cities that work in close partnership with the WHO. Its aim
is to promote health in the urban context by identifying and
counteracting aspects of urban life that impair health.
 The Elements of People-Centred
 Health Promotion (Raeburn And
         Rootman, 1998)
The mnemonic ‘PEOPLE’ defines this approach:

     Organizational and community development
     Life quality
    Community development

1 Participatory formulation of a philosophy of
action and overall objectives.
2 Participatory planning of action through
community needs assessment.
3 Consensual setting of time-limited goals.
4 Consensually agreed resource plans.
5 Allocation of tasks and actions to as many
participants as possible.
6 Regular review of all major project goals and
processes in a public forum.
7 Periodic assessment of outcomes.
Healthy living centers (HLCs)
In the UK the government allocated £300 million
from the National Lottery ‘New Opportunities
Fund’ to the development of healthy living
centres over the period 1999–2003. A total of 349
projects were funded across the UK focusing on
the health of the most vulnerable 20% of the UK
population. The HLCs work with local priorities
for improving public health and tackling social
exclusion as well as supporting government health
policies. The maximum grant scheme length was
five years. Support of HLC is expected to finish
by 2008. HLC are expected to be self-sufficient
after this period.
               HLCs evaluation
Results are expected in August 2005. An interim evaluation
report stated that HLCs are successfully targeting
disadvantaged sectors of the society. Data collected from 96
HLCs in 2003 showed that the majority of users were
women (72%). Forty-four percent were over the age of 55.
Twelve percent were from ethnic minorities. Twenty three
percent were employed and 10% were ill or disabled.
Approximately one third of the 3,399 respondents said that
their health was only fair or poor. Most HLCs users (88%)
had a good opinion of the services/facilities offered.
However users from ethnic minority groups and those with
poorer general health held less favourable opinions than
other groups (Bridge Consortium Team, 2003).
      Collective action as
    community empowerment
Outreach health education with intravenous drug using
communities at risk of HIV infection provides a good
example of the collective action approach (Rhodes and
Hartnoll, 1991; Rhodes, 1994). Community outreach
strategies aim to achieve subcultural change among target
constituencies. Outreach involves the use of key members
of the target community as indigenous workers who
communicate a series of complementary risk reduction
messages to other members of the community. In addition,
such strategies can be incorporated within existing self-help
initiatives that aim to achieve wider social and political
    Participatory action research
The Junkiebonden, a federation of Dutch self-help groups,
aims to initiate community change through campaigning
for the modification of local and national drug policy. The
Junkiebonden was involved in the setting up of the first
syringe exchange in the Netherlands in 1984. Since then,
it has distributed education and prevention materials to
drug users and sex workers through outreach techniques.
The Junkiebonden was set up from within the drug-using
community and is run predominantly by current drug
users. This was a grass-roots initiative that did not require
external facilitation.
    Evaluation of the needle
     exchange programmes
Since the establishment of the needle
exchange network in Amsterdam the rate of
HIV infections has decreased. However,
national and regional legislation and
policing policies play a key role in the
effectiveness of outreach work. Evidence
from evaluations of needle exchange
programmes in the USA and UK is less
encouraging (e.g. Stimson et al., 1991).
      Campbell’s peer-education
    programme among sex workers
In an isolated 400-person shack settlement in a southern
African gold mining community where more than six out of
every ten women were HIV positive. The programme aimed
to increase knowledge about sexual health risks and
personal vulnerability to HIV infection, to encourage people
to seek out early diagnosis and treatment, and to encourage
the use of condoms. The programme was based on the ideas
of critical consciousness of Freire and of bonding and
bridging social capital as suggested by Putnam.
Criticisms of the collective action
    vulnerable to lack of funding and to
    official oppositions

    danger of creeping professionalization

    problematic concept of ‘community’

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