Health promotion is a vast and complex subject, encompassing aspects of definitions of health, practical and political approaches to promoting health, education, social policy and particular notions related to preventative approaches to lifestyle management. As such, it requires careful examination and consideration in terms of the current UK socio-political culture and in terms of the evolution of health promotion into its current state (Scriven and Orme, 2001).
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Health promotion involves a great variety of people, professions and players, including politicians, doctors, nurses, social care professionals, teachers and educators, the legal profession, and of course, the general public. It touches everyone in our society in one form or another, from the advertising on cigarette packets to the nutritional information displayed on supermarket foods. Therefore, it is of concern to everyone in society, because it considers health, however it is defined, as being to a certain degree manageable, in that the manipulation of lifestyle and environmental factors can support people in achieving optimum health and wellbeing. However, its very complexity, partly due to its historical evolution, partly due to the complex social and political interactions which define the sphere of health in society, can mean that simplistic notions of health, health promotion and associated concepts are difficult to define and to achieve.
This essay will address some of the complexities of the issues of health promotion. It will attempt to define what health promotion is, what ideas, ideals and concepts it includes, and how health promotion is realised in a practical sense. It will also address the need for exploration of the outcomes and interactions of health promotion activities, and their social and institutional context. It will, of necessity, discuss aspects of the healthcare systems within the United Kingdom which pertain to the subject, and of the socio-political systems and histories which underpin the current climate. It will then examine vital aspects of health promotion, such as health education and communication, participative approaches to health promotion, and evaluation of health promotion initiatives. The author will also attempt to debate ethical, political and professional dilemmas that arise in new practices and policies for promoting health and explore the development of ways of promoting health that tackle social and economic inequalities and that are holistic and culturally sensitive.
What is Health Promotion?
Tones (2001) describes health promotion as a contested concept, raising immediately the notion of differing definitions of health promotion, perhaps based on different conceptualisations of health or different social or political imperatives. Health promotion has often been viewed as synonymous with health education, while health education conversely is often believed to be a fundamental component of health promotion (Tones, 2001). It is also linked with and perhaps interchangeable with definitions of public health (Tones, 2001). This relationship with public health immediately takes the notion of health promotion away from the individual sphere and places it firmly in the public sphere, within the context of the social and political systems of the nation in question, or within a global perspective, both of which are applicable to this essay and discussion. Tones (2001) suggests a formula for health promotion where healthy public policy is multiplied with health education, establishing their relationship as the basis for our definitions of the concept. The World Health Organisation defines health promotion as the process of enabling people to increase control over, and to improve, their health. This generic definition suggests that health itself is an individual state over which individuals can have some measure of control. Jones et al (2002, p.xi) also suggest that for many people, health promotion means targeting behaviour, but view it as something imposed upon them which does not necessarily work for them.
However, given that promoting heath is a diverse, complex and multi-faceted activity (Jones et al, 2002, p5), these definitions do not address the range of activities and ideologies associated with the process. Health promotion policy appears to combine diverse approaches which include legislation, financial measures, taxation and organizational change. Tones (2001) simplistic suggestion of a formula of the interdependence of health education and healthy public policy as a definition of health promotion does not focus on the role of the individual. Both are equally important in our understanding of this issue. Tones (2001 p4) however further goes on to discuss a model of health promotion which focuses on the purpose of healthy public policy and health education, which is argued to be the empowerment of individuals and communities to reduce or remove the various barrier spreventing the attainnment of health for all. This is a more useful definition, but rather idealistic, as it suggests that such a goal is achievable, and there may be vast differences in individuals’ notions of ‘health’ and their abilities to achieve this.
Health promotion and health education are often also seen as synonymous. Health education can be as complex an issue as health promotion to define. Education implies somebody ‘teaching’ or educating, and somebody learning new information. Tones (2001) p 15) describes emancipatory education, a dialectical process which involves critical consciousness raising which leads to the translation of critical thinking about social issues into action. Health education involves communication and the transmission or sharing of information, but also implies that such information must be assimilated by the recipient and then utilised in order to bring about change in the self or in aspects of behaviour, lifestyle or environment.
There are great benefits in adopting the curent collective approach to promoting health, which aims to involve people not only in their own health and well-being but in acting together upon theirf physical, social, political and economic environment for the sake of health (Sidell et al, 2002, p 1). Such approaches allow for the incorporation, validation and promotion of individual and group needs based on diversity in race, ethnic or religious identity, social or lifestyle identity, social status and social and geographical inequality.
Historical Milestones in Health Promotion
Webster and French (2003 p9) suggest that while the immediate sources of health promotion and current approaches to public health lie in the political history of the 1970s, there are roots which go much further back, arguing that all communities have had some interest in co-ordinated community action to ensure a better life. The historical link between health promotion and public health is well established, with one of the most significant milestones being the formation of the National Health Service in 1948, whose medicalised approach initially hindered public health and health promotion initiatives as we see them today in favour of a treatment-oriented approach to illness (Webster and French 2003 p 10).
Webster and French (2003 p11) suggest that the three seminal documents which launched what we know perceive as the health promotion movement were: the Lalonde Report New Perspectives on the Health of Canadians (1974); the World Health Organisation’s Global Strategy for Health for All by the Year 2000 (1981) and the Ottawa Charter for Health Promotion 1986). It was these documents which, collectively, set out a vision for health improvement which exceeded the traditional approaches of sanitation engineering, lifestyle health education and preventing and caring health services which characterised health promotion to that point. Instead, health promotion became concerned principally with empowering citizens that that they could take control of their health an in so doing attain the best possible chance of a full and enjoyable life (Webster and French, 2003, p 15).
This notion of empowerment appears fundamental to current perspectives on health promotion and to its influences on the National Health Service, including on such concepts as patient participation and collaboration, service user involvement and patient rights. This heralds a move away from the medicalisation of health towards a more social definition of health where power is apparently distributed more equally among those who experience and those who purport to affect health, illness and wellness. This is something that the World Health Organisation appears to have consistently advocated, a positive and holistic view of health which comprises mental, physical and social elements (Tones, 2001 p6). The Ottawa treaty, which encompasses the key principles of equity, empowerment and the reorientation of the health services, reflects this notion of demedicalisation, where collaborative working by the many agencies concerned with health promotion is believed to maximise the potential of any strategy or policy in this arena (Tones, 2001, p7).
Within the UK, policy drivers which have driven health promotion initiatives are too numerous and complex to fully explore within the context of this essay. However, governmental initiatives, changes in health and social services, changes in approaches to public health and changes in statutory control and responsibility for public services have all formed part of the UK health promotion focus (Jones et al, 2002 p 9-13). However, there appears to be a counter culture of bottom up drivers as well, with empowerment leading to the enabling of the activities of community and voluntary groups to bring about change at local and even national levels. This reflects the overall picture of holistic health promotion as a community development activity rather than a policy founded in political rhetoric.
Contextual and Practical Issues in Health Promotion
The setting of health promotion is also of some concern, with the role of the media, community development and critical consciousness raising (Tones, 2001, p14-15) still areas of some debate. This author would argue that the media may have some merit in health promotion, but that there are likely to be many who do not trust the ‘messages’ given out given that so much advertising is false, suggestive and manipulative, and based on the need to sell products rather than truly promote health. Health and community services appear to be the most impactful arenas for health promotion to take place within.
The National Health Service has already established a policy context for the promotion of health within public services (Adams, 2001 p35). Therefore, a primary and important leader for health promotion is the health authority, with its twin roles of service improvement and strategic leadership for improving health and tackling health inequalities (Adams, 2001, p38). Activities such as health needs assessments and community planning can be carried out in a collaborative and participative way with local organisations and community groups in order to target and focus health promotion activities at a policy level (Adams, 2001, p 39).
Primary healthcare services and Primary Care Groups can also be a vehicle for health promotion (Velleman and Williams, 2001, p43), and given their location within communities should be ideally suited to this role. Such groups can focus on practical initiatives to reduce inequalities in health and to target issues such as heart disease, cancer, teenage pregnancies and accidents, on the back of governmental initiatives, alongside emergent and self-defined local issues (Velleman and Williams, 2001, p43).
An example of an activity by a primary care group is of a stop smoking initiative, whereby health professionals were trained and located in GP practices to provide one to one support to smokers who want to quit, and practices were supported in developing systems that deliver stop smoking interventions effectively (Velleman and Williams, 2001 p 44). Such practices can have multiple benefits, both to the individuals whose health is improved by the intervention, and to their communities. The wider impact is also that such practices can serve as examples and provide evidence for other groups wishing to develop similar interventions. So it would seem that local initiatives can be of much wider importance. GPs have, following changes in contracts, been charged with the responsibility of improving the public’s health (Jones et al, 2002). But the limitations of their services, their training and their scope are still apparent (Jones et al, 2002).
The National Health Service also has an already established professional context which is ideally suited to taking forward notions of true, holistic health promotion whereby communities and individuals become empowered as agents of their own wellbeing. Community nursing services, again on the frontline of NHS care and which function fully within the communities they serve, can be a vehicle for such activities (Wright, 2001, p58). These work alongside specialist health promotion services who act as catalysts and facilitators at local levels (Learmonth, 2001 p 66). Such professionals and services can be active in organisation development, through leadership, partnership, development, training, education and support and policy and strategy development (Learmonth, 2001, p66). They can also engage in evidence based practice, market research, communication and publicity, and programme management (Learmonth, 2001, p67). The benefits of having such professionals are obvious, particularly within the already overstretched and under-funded health and social services sector. Such activities appear vitally important to achieving health promotion goals, and in particular to ensuring collaborative working and full community engagement. Therefore, specialist services can also support community development through advocacy, needs assessment, community participation, information for health, and evaluation of services (Learmonth, 2001, p 67). However, there are challenges, particularly in the capacity and recognition of such services and their location, which may fall between traditional services and serve to hinder their function (Learmonth, 2001, p75).
Hospital nursing practice also provides vast scope for health promotion (Latter, 2001, p77). Among other potentialities, the role of the hospital nurse as the primary caregiver for individual patients equates to a significant scope for health education (Latter, 2001, p78). However, there is also the need to further develop this role, and support its expression in the beleaguered health service (Latter, 2001, p 79). Despite the challenges of this, it could be argued that nurses have a strong role to play in creating environments that are supportive of health, encouraging community participation in health and helping to generate healthy policies (Latter, 2001). It should be remembered, however, that nurses are themselves individuals, whose own health needs support and input, and so any drive towards increasing their functions within health promotion may also need to address their working conditions, and the demands which place a strain on their own health.
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Environment is another contextual issue in health promotion. The role of Local Authorities in supporting healthier environments and communities is described by Allen (2001, p 91), who argues that such authorities can act as role models, and through the work of environmental health services, can promote the health of communities through: food inspection and maintenance of food safety; housing standards; health and safety at work and during recreation; environmental protection; communicable disease prevention and control; licensing; drinking water surveillance; refuse collection and street cleaning; and pest control. These are statutory functions, but if effective and efficient, have obvious public health benefits and therefore health promotion benefits. In addition, the discretionary powers of local authorities can affect issues of HIV and AIDS, alcohol and drug addiction, nutrition, women and men’s health, heating and energy advice, occupational health, environmental enhancement and poverty issues (Allen, 2001 p 91). Their limitations are apparent, but this is where the voluntary sector comes in, and often voluntary groups and agencies fill some of the gaps where statutory services cannot stretch to cover all areas.
Social services address the social aspects of health, by engaging in preventive work with children and families, by involvement in the care of older people, and by engagement with the health and wellbeing of people with special needs (Jones and Rose, 2001 p 95-102.) Diversity issues can be addressed by some aspects of social services (Jones and Rose, 2001 p 95-102), but again, there are gaps, where in some areas voluntary agencies can fulfil identified needs that cannot be met by health and social care services. Another arena for health promotion is that of health education in schools (Scriven, 2001 p 115). This is another growth area, supported by a range of policy drivers (Scriven, 2001, p121; Beattie 2001 p 133). School nurses have always had a role in health promotion for specific age groups, and this is another area where health promotion opportunities can be maximised (Farrow, 2001 p 151). Similarly, there is some evidence that Universities can be effective loci of health promotion activities, with the integration of visions of health within plans and policies and promotion of sustainable health within the wider community (Dooris and Thompson, 2001 p 160). For those who perhaps cannot be reached through these contexts, there is also the Youth Work setting, which also provides considerable scope for health information and advice, though this too is not without its challenges (Robertson, 2001 p 173-176). Where services fail to meet need, as already suggested, the voluntary sector may cover the shortfall. The greatest value of the voluntary sector lies in its diversity and its motivation, which stems from free will, moral purpose and individual personal engagement (Anderson, 2001 p 181). Voluntary agencies are non-profit-making and occupy a singular position within society. Conversely, profit-making agencies can also contribute to health promotion through health working policies and health promotion in the workplace (Daykin, 2001 p 204). Good occupational health services, for example, can also play a vital role in health promotion, both generally and in specific issues related to the type of employment and activities concerned (Lisle, 2001).
What all of these point to is this notion of collaborative, interagency working, where health promotion becomes the common goal of diverse populations, agencies, services, professions and of course individuals. Some believe that effective interagency working lies at the heart of improving health outcomes for vulnerable populations (Jones and Rose, 2001, p 95). However, such a standard of working is difficult to achieve (Jones and Rose, 2001, p 95), perhaps because of the boundaries and restrictions within which such groups work, and the historical context which makes them protective of their own ‘territory’. It is obvious that such limitations must be overcome if health promotion goals are to be met. It we are to achieve the goal of a holistic, socio-ecological model of health fully applied to our societies, then new ways of working and communicating must be developed, building on current evidence from innovations and practice.
Debates and Dilemmas in Health Promotion
It would be reasonable to raise the question, in the light of all these services, policies and drivers which promote health in our arguably well-endowed nation, why indeed is health promotion still such a challenge? Why are so many still suffering from ill health, social injustice, health inequalities and supposedly eminently preventable diseases? There may be many possible answers to this. Health is believed to be ultimately determined by the existence of equity and social justice, which is in turn rooted in people’s material, social, economic and cultural circumstances (Tones, 2001 p7). It is also believed that community action for health is based on the premise that health chances and health choices are shaped, to a great extent, by the social, political and economic conditions in which people live, and that ability of individuals to shape and control these structures is limited (Jones et al, 2002 p 25).
It has been argued that the creation of healthy public policy is the prerequisite for changing adverse environments in order to facilitate the development of health (Tones, 2001 p8), but this author would also argue that adverse environments must be ‘ owned’ by those who live within them, and no amount of policy, imposed ‘top-down’ will improve environments if those who live within them do not equally invest in their amelioration and long-term development. Tones (2001 p 9) does argue that individual empowerment and community empowerment are linked, and that these are partly dependant on a sense of community where individuals have some notion of membership of some kind of community or group. The term community implies a common bond between individuals (Jones et al, 2002 p 25). Therefore we see the individual in a different context, a context comprised of various relationships and connections with other individuals. These must surely affect health and health promotion behaviours, positively and negatively.
But what of the individuals who fall outside such communities? Is it the remit of government, at any level, to force or coerce individuals into a state of ‘belonging’? Definitions of communities and group identities may serve to alienate those who do not feel associated with them, but in this case it might be necessary to focus on the good of the many, and to address the larger issues before addressing individual differences of this kind. If self-empowerment is attainable (Tones, 2001 p 11) then such individuals may take control of their own health. Activities such as community campaign groups, self-help groups and even more politicised groups related to notions of women’s or men’s health may all engage in action for health (Jones et al, 2002), and therefore it could be argued that any one individual should find a group or action which ‘concerns’ them or some aspect of their life or lifestyle. This may be particularly important in terms of diversity, where so-called ‘minority’ groups can both campaign for issues pertaining to their own identities and needs, and develop services which meet those needs.
This returns us to the work of the voluntary sector, which is where such activities tend to find expression. But surely it is the role of government, and the services provided, at a locally devolved level, through central funding, to provide such sensitivity in the services and policies it underwrites? Some would argue that such sensitivity exists, but we have yet to see it fully realised in action, and have yet to see evidence of the efficacy of these great policy drivers in real practical terms. Jones et al (2002 p 47) suggest that community groups may find it useful to develop partnerships with local authorities, the education sector, other groups, NHS services, employers and even the media in order to ensure a fully participative, collaborative and comprehensive approach to locally-suited health promotion activities. This author would argue that with the best will in the world, there will always be a divergence between the goals of different groups, and an imbalance of power between these different agencies.
The agendas of central government may end up dominating those of the community, and while such collaborative working is the ideal, it may need to be undertaken with awareness and caution. Farrant (2003 p 230) argues that the recent moves towards community development may simply mirror or reinforce the existing power inequalities within social systems, and such activities simply serve as another vehicle for governmental control. It is therefore important to be aware of the policy context within social action on health promotion, and to engage in true community or communal activities rather than those made possible by the current political and funding context.
The paternalism of our current political system is evident in the media and the governmental policy drivers which shape public services. Such paternalism may be of some benefit in highlighting health promotion issues which need to be addressed, but the media reports demonstrate an over-generalisation of the issues. It is at the community level that the real needs can be identified (Jones et al, 2002 p 100). Part of this process is the evaluation of health promotion initiatives and actions, particularly participatory evaluation of community action with dissemination of findings (Jones et al, 2002 p 100). This serves two purposes. It allows communities themselves to build on evidence and continue to grow and develop such initiatives in a reflexive manner, and it establishes their work within the fields of health and social care on a more critical, intellectual level as an evidence-base which can educate and empower others.
This essay has touched on the notion of public health and policy drivers, and has equated health promotion, to a certain degree, with the notion of public health. It is important, therefore, to consider the public health debate and the politics of health promotion. The context of public health within the UK is very much concerned with the notion of health inequalities, again, as mentioned in the above discussion. The evidence from the UK still points to considerable inequalities in health depending on region, and on individual occupation, and suggests that these inequalities are widening, despite significant improvements in aspects of social and economic wellbeing (Graham, 2003 p 20). Changing distributions of work and income, changing access to housing (such as increases in owner-occupation), changing patterns of working and domestic lives are all affecting social determinants of health (Graham, 2003 p 24-25). It has long been believed that income inequality is an important determinant of health in richer societies, but research suggests that population health is related less to how wealthy a society is, and more to how equally or unequally this wealth is distributed (Graham, 2003 p 25).
But individual factors must be taken into consideration, particularly in terms of health and illness. It is no surprise that an individual’s health is a determinant a well as an outcome of socio-economic circumstances, where those in better health are more likely to move up the occupational and economic ladder, while those in poorer health will not (Graham, 2003 p 26-27). Factors on the individual level include material factors, such and the physical environment of the home, the neighbourhood and workplace, and living standards; behavioural factors, such as health-related routines and habits, leisure activities and diet; and psychosocial factors in particular increased stress and risk-taking behaviours (Graham, 2003 p 27-28).
Public health therefore has a dual remit – to address the socio-economic factors which affect health, and to address the individual factors which influence health. There is evidence of addressing individual lifestyle factors in governmental paternalism in such campaigns as the no-smoking campaigns and legislation, and the current debate on obesity. However, the notion of the evidence which underpins these drivers is debatable. There has been in recent years, a strong trend towards evidence-based practice in all aspects of health care, and this includes health promotion and public health (McQueen and Anderson, 2003 p 165). Ideally the theory informing practice should arise from multiple disciplines and represent diverse research (McQueen and Anderson, 2003 p 167).
However, there is a divergence between empirical evidence and so called qualitative evidence, the latter of which does not enjoy the validity or acceptance of the former in terms of evidence. While health promotion is widely assumed to be based on science and a scientific basis for human behaviour, a scientific paradigm does not underlie our notions of health, public health and health promotion (McQueen and Anderson, 2003 p 168). The whole concept of public health and health promotion stems from an holistic and almost communalist paradigm, rejecting the view that human behaviour is simply a response to physiological and neural processes (MqQueen and Anderson, 2003 p 168). Therefore, simplistic, reductionist and scientific principles of evidence derived from statistics and experimental research will of necessity be woefully inadequate in addressing the very real complexities of health promotion in the practical and real community context. Therefore there is a need to identify news ways of seeking and defining appropriate evidence, in a developmental process which mirrors that of the health promotion activities themselves.
It is evident that health promotion, particularly within the UK context, is a complex concept with a wealth of diverse yet oddly inter-related issues and problems. This essay has attempted to discuss some of the issues raised in the set books for the K301 course, with an exploration of key issues and some debate of current provision. Health promotion is a governmental initiative, but remains also an ideogical and idealistic goal. It is best viewed as an holistic concept with contextual characteristics which must be taken into consideration. Some of these contextual characteristics are national, some are local or locational, and some are individual. It is the relationship between these three that defines both the need and the processes required to meet that need, fundamentally at a local level.
The very complexity of the context requires that health promotion activities occur through collaborative, communal and partnership working, which means a change from traditional methods of organising health and social services. If we accept the principle that coordinated action leads to improved health, income and social policies that foster greater equity, then we understand the fact that collaborative action contributes to ensuring safer and healthier goods and services, better and more locally suitable public services, and cleaner, more healthful environments. It also requires that policy-makers, groups and individuals identify barriers and challenges to the adoption of healthier policies and behaviours, throughout society, and develop collaborative approaches to addressing these. However, avoiding paternalism and the mimicking of governmental agendas is also vital.
What is most apparent from this discussion is that despite the debates, and there are many, the systems and resources are already in place to foster improved public health and health promotion activties and to engage all sectors of the community in these actions. Such resources include primary healthcare services and groups, nurses working in acute hospitals and within the community, specialist health promotion professionals, social services, schools, voluntary agencies, statutory agencies, youth groups, social and self-help groups, and many more. The potential of these groups in and of themsleves to engage in health promotion, and to evaluate and communicate these activties to others as a form of evidence, is already apparent from the literature. In particular, the literature also suggests that the notion of evidence in this arena should move away from reductionist, scientific principles to mirror the holistic nature of the health promotion context. But the efficacy of these diverse players in the arena is limited until such time as full collaboration, partnership and inter-agency working is realised.
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