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Concept	of	Health	Promotion
Rakesh	Singh
BPH,	MPH,	DGH	
Nepal	Bidhya Bhusan
Lecturer
School	of	Public	Health
Patan Academy	of	Health	Sciences
6/1/18 Concept	of	HP	- Rakesh	Singh
Nowadays we hear a lot about Health Promotion (HP)....
People refer to it in workshops and meetings....
Directors in DOHS use this term to describe nature of their work
and development workers discuss HP in relation to health
campaigns...
But what is HP?
What does it aim to do?
What ideas underpin HP?
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK 1 - Identify common features of Health Promotion
projects/programmes
What	examples	of	Health	Promotion	projects	or	campaigns	
do	you	know	of,	either	at	a	national	level	or	in	your	local	
district	or	region	or	state?	
What	do	all	these	projects/programmes	have	in	common?	
6/1/18 Concept	of	HP	- Rakesh	Singh
National	HP	projects What	they	have	in	common
Open	Defecation Free	Campaign § They	raise	awareness	and	
promote	skills	to	assist	
people/groups	to	change	
behaviour	that	is	detrimental	to	
their	health.
§ They	develop	supportive	
environments	in	which	healthier	
choices	are	easier	choices.
§ They	… improve	health
GBV: Zero	Tolerance
Red	Ribbon	HIV/AIDS	Awareness	
Campaign
Child	Abuse	Helpline
Health	promoting	settings,	e.g.	
Health	Promoting	Schools	
Health	warnings	on	tobacco	
advertisements
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
• .....HP programmes are often not flagged or labelled as such.
• Instead, they are often found embedded within the broad
activities of health and developmentorganisations.
• They are also found in a variety of different settings, and
assume different approaches.
• HP activities are likely to be hidden within comprehensive
integrated health activities of inter-sectoral action.
6/1/18 Concept	of	HP	- Rakesh	Singh
Other	common	features	of	HP	programmes
• Provide information about health enhancing initiatives, health
issues or a particular behaviour that has a negative effect on
health e.g. no smoking campaigns.
• Refer the public to other supportive structures or organisations
that provide additional support to the particular issue e.g. a
Childhelplinecounsellingservice.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Encourage the development of working partnerships across
different sectors e.g. between health and transport, housing,
engineering and planning.
• Contain health promoting messages that are targeted at
specific audiences and sometimes, developed in consultation
with the target audience.
• Contribute towards the development or implementation of
healthy publicpolicy.
6/1/18 Concept	of	HP	- Rakesh	Singh
Before	exploring	these	Health	Promotion	
features	further,	let	us	look	more	closely	at	
what	we	mean	by	the	concept	Health	
Promotion.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Looking	at	any	complex	society,	one	can	identify	three	
overlapping	sectors	of	health	care:	
1. the	popular sector	i.e.	the	lay	or	non-professional	
sector;	
2. the	folk sector	i.e.	the	traditional	or	sacred	sector	
3. the	professional sector	i.e.	the	legally-sanctioned	
sector	such	as	western	scientific	medicine.	
• Each	sector	contributes	to	how	one	might	experience	
and	interpret	what	being	healthy	or	sick	means.	
6/1/18 Concept	of	HP	- Rakesh	Singh
• For example, under popular sector, one might start
constructing one’s idea about health and illness from personal
experience.
q Experience of being sick, or taking care of family who is sickly.
q Listening to neighbourhood or community beliefs or advice
about how to keep away colds in winter or how important it is
to eat certain foods to combat a particular illness.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Under folk sector, one construct ideas about health and illness
from a traditional healer, a diviner or a spiritualist.
q Health and illness is viewed by many in this sector as holistic
with all aspects of life being equally important.
q In other words, one’s relationship with others, the natural
environment, supernatural forces and any physical and/or
emotional symptoms would all be considered in a
consultationwith such a healer.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Professional sector - western scientific medicine or allopathy,
includes medical practitioners. This sector holds a dominant
positionin our society.
• People’s ideas about health and illness will not be constructed
from any sector alone – nor will they necessarily seek relief
from illness from a single health practitioner or healer.
• A health worker need to move between the popular, the folk
and the professional sector.
6/1/18 Concept	of	HP	- Rakesh	Singh
Understanding	the	Perception	
regarding	these	differences
?
6/1/18 Concept	of	HP	- Rakesh	Singh
DIFFERENT	CONCEPTS	OF	HEALTH
• Difficult to define as everyone has a different concept of
health
• But it can be conceptualised or understoodmentally
• In other words, you can describe your concept of health but
not necessarily define it.
• The important thing is to think about your concept of health
and to be able to articulate and communicate it to others.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Equallyneed to respect other’s concepts of health.
• If to my neighbour or my colleague, being healthy means
being fit and never being ill, whereas to me health means to
have a sense of wholeness, well-being and peace – one should
acknowledge and respect this difference in opinion.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd..
• Many researchers and writers have explored different
definitionsor concepts of health.
• Discussed in terms of lay and health professional concepts or
definitionsof health.
• For example, a British Sociologist, Mildred Lillington Blaxter
(1990) working from a British sample of 9000 people, grouped
their lay definitions of health into a number of different
perspectives. It included:
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Health as not ill or diseased i.e. the absence of disease.
• As individual behaviour e.g. if someone lives in a healthy way,
does exercise and or does not drink or smoke.
• Physical fitness e.g. being fit or strong, or lookinghealthy.
• Energy e.g. having energy and enthusiasm to do things.
• Social relationships e.g. health in terms of relationships with other
people.
• Function e.g. being able to carry out normal routines or having the
ability to do things.
• Psycho-social well being e.g. being in a state of good mental
health.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd..
• Consider how important it would be if you were developing a
national HP campaign (for example with the 9 000 individuals
that Blaxter included in her sample), to bear in mind just how
diverse people’sideas about health are.
• Also important to bear in mind the influence that the popular,
folk and professional sectors have on influencing your
audience’s interpretationof health.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Discussing professional as opposed to lay perceptions of
health, it is notable that perceptions are influenced by
particular model of health or illness to which they subscribe.
• In HP literature there are often references to two opposing
views of health: the bio-medical model and social model of
health.
6/1/18 Concept	of	HP	- Rakesh	Singh
Medical	and	Social	Models	– two	views	of	health
• Bio-medical- “the absence of disease” ....Assumption-disease is
generated by specific agents- changes in the body... Emphasises the
importance of alleviating symptoms or curing diseases.
• Define health “… more by what it is not than what it is”.
• This model halts its analysis at the actual disease – exploring other
determinants (apart from specific agent).
• Limited emphasis on preventionof disease.
6/1/18 Concept	of	HP	- Rakesh	Singh
Social	Model
• Views health and ill health as being caused not by diseases alone
but by social conditions(poverty, gender, violence.....)
• Emphasises positive side of health...Defines-in terms of a state of
well-being.
• The link between the physical, psychological and social processes
also suggests that health is more holistic in nature, as is illustrated
by WHO Definition.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Health Promotion: A Discussion Document on the Concept
and Principles, WHO – health as a human right and something
which requires prioritisation and social investment by all,
including governments, organisations, business and others.
• “The extent to which an individual or group is able,...to realise
aspirations (desire) and satisfy needs, and...to change or cope
with the environment. Health, therefore, is seen as a resource
for everyday life, not an object of living; it is a positive
concept emphasising social and personal resources, as well as
physical capacities” (WHO, 1984).
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK		2	- Classify	different	perceptions	of	health
Responses to “What is needed in order to feel healthy and live a healthy life?.
Classifythese responses accordingto the two different models ofhealth.
Having	money
No	natural	disasters	(e.g.	floods)
Having	interesting,	challenging	work
Having	a	flushing	toilet
Good	roads
Feeling	secure	from	danger	or	threat
Not	to	have	diseases	I	can’t	easily	cope	with	
Not	to	have	TB
Not	smoking
Protected	from	discrimination
Having	good	friends
Having	a	job	
Having	a	house
No	violence	
Feeling	happy
Having	enough	food
Feeling	well,	happy,	stimulated	by	life	and	
spiritually	content
A	clean	environment	
Feeling	spiritually	fulfilled	
Being	fit	and	lean	
To	feel	strong	and	keen	to	take	on	new	
challenges	
6/1/18 Concept	of	HP	- Rakesh	Singh
a. Different ways of classifying these responses.
b. Being healthymeans different things to different people.Influenced by:
q The context in which they are living e.g. geographical or physical location,
housing,income,employment status.
q Current health status.
q Knowledge,experiences and beliefs about health.
As a health promoter, it is always important to reflect on what being healthy means
to you and what it means to your clients, .... important influence on the approach
to HP.
c. As a health promoter there will invariably be things that you cannot directly help
your clients with.
For example, ensuring that there is an accessible, well maintained and safe public
transport system falls outside of health service’s responsibility. However, a health
worker.....start lobbying...to put more traffic officers on duty around schools and
parks, or to run educational campaigns about road safety at primary
schools.....HW begin to work inter-sectorally to reduce the high rate of traffic
accidents or to increase road access to rural villages.
Professional skills or experience Broader developmental issues
6/1/18 Concept	of	HP	- Rakesh	Singh
BIO-MEDICAL MODEL OF HEALTH
INDIVIDUAL COMMUNITY
§Not to have diseases I
can’t easily cope with
§Not	to	have	TB
§To	quit	smoking
§To	be	fit	and	lean
§To	feel	strong	and	keen	to	
take	on	new	challenges
§Having	money
§Having	a	job
§To	be	happy
§Protection	from	
discrimination
§Having	good	friends
§No	violence
§Good	roads
§A	clean	environment
§Having	a	house
§Feeling	secure	from	danger
§Having	a	flushing	toilet
§Having	enough	food
§No	natural	disaster	(e.g.	floods)
§Having	interesting	work
§Feeling	spiritually	fulfilled
§To	feel	well,	happy	and	stimulated	
in	my	life,	and	to	be	spiritually	
content
SOCIAL MODEL OF HEALTH6/1/18 Concept	of	HP	- Rakesh	Singh
Dimensions	of	health
• When people speak about being healthy, they refer to a
number of different areas of their daily lives.
• These different areas have been conceptualised as different
dimensions of health.
6/1/18 Concept	of	HP	- Rakesh	Singh
PHYSICAL MENTAL
EMOTIONAL SOCIAL
SPIRITUAL SEXUAL
ENVIRONMENTAL
SOCIETAL
Dimensions of Health
6/1/18 Concept	of	HP	- Rakesh	Singh
Individual	D
Broader/Societal	D
Health	
interrelated	to	
all	aspects
“Holistic	
Concept	of	H”
TASK	3	– Define	(Health)	Promotion	
a) What	does	promote	or	promotion	mean	to	you?	
b) Given	your	concept	of	health,	what	does	Health	Promotion		
mean	to	you?	
c) In	order	to	promote	health	what	information	do	we	first	
need	to	understand?	
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
a) To promote means to advance, assist, encourage, lend support to,
market, publicise, help the progress of something, push for.
b) Health Promotion means to advance, to assist or to push for a
better healthier life for people.
To use an analogy: health and development workers often feel like
they spend all their time standing on the banks of fast flowing river
lifting people to safety. The health promoter works upstream and
tries to find out why people are falling into the river from the
beginning and how one can work together in preventing such
things from happening in the future.
c) In order to promote health effectively with individuals and
communities, first need to understand the causes or determinants
of ill-health.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants	of	Health
• Two other factors which affect our way of seeing or
conceptualisingHP:
1. Determinants or causes of health and ill health
2. Inequity and explore how these factors impact on definition
and understandingof HP.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Like your definition of health, what you view as the
determinants or causes of health also influences your
interpretationof HP.
• They affect the way you view the purpose of HP and the kinds
of interventionsthat you choose to make.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK 4 - Identify some of the determinants of health and ill-
health
Jot down categories of determinants or causes of health or ill-
health and rank them according to which ones you think are the
most important or have the most influence.
6/1/18 Concept	of	HP	- Rakesh	Singh
1. Genetic factors - determine individual’s predispositionto disease.
2. Biological factors - diseasecaused by bacteria or viruses.
3. Individual behavioural factors - contribute to disease, such as smoking,
drinking, lack of exercise.
4. Socio-culturalfactors,such as traditional,religious beliefs and practices.
5. Factors around work and living conditions, such as housing, sanitation,
transport, access to health services, income, adequate nutrition and
employmentopportunities.
6. Environmentalfactors,such as pollution, level of violence.
7. Broader political, economic and social factors, such as a country’s
constitution and laws, prevailing economic system, the available
resources and how these are distributed.
These factors affect the way in which a society is structured or
stratified, e.g. in terms of class, gender, race, age. They also impact
upon the other factors.
DETERMINANTS
6/1/18 Concept	of	HP	- Rakesh	Singh
Ranking	of	Determinants
• Influenced by your view of health and in turn influence where you, as a health
promoter,place your efforts.
• Depend on your judgement of the issues, but also the perspectives of those you
work with and the feasibilityofanyintervention.
• For example, if you were working with a group of youth and believed that
individual behavioural factors as the most important determinant to tackle, you
might focus on individual skills building session. These could include discussion
sessions on how youth could stop smoking or taking drugs or how they should
practise safer sex or encourage youth to take up some form of sport.
• However, if environmental factors such as the high levels of violence or factors
associated with poor living conditions were seen as priorities, you might focus
on advocating for the development of community safety programmes, or for
changes to be made in the design and layout of low-cost housing schemes, and
you might work with the local communities to become involved in lobbying for
stricter legislation regardinggender-based violence.
6/1/18 Concept	of	HP	- Rakesh	Singh
How	the	categories	interact
• Political, economic and social factors - affects the other categories in various
ways.
• For instance, consider how the following government laws and policies could
determine and change economic and social conditions and how those changes
would impact on other levels of health:
q Providinghousingsubsidies for the poor.
q Expandinglocal health facilities to rural areas.
q Ensuring equal work opportunities for men, women and the physically
challenged.
q Restrictingthe levels of industrialpollution.
q Assertingthe propertyand inheritance rights of women .
q Supportingthe right of women to terminationofpregnancy.
q Banningsmokingin publicplaces and prosecutingdrunken drivers.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• This intervention could improve the environment as well as the working
and living conditions. It could also challenge unhealthy cultural and social
practices, and reduce the negative effects of these factors, particularly on
the health status of disadvantaged or vulnerable groups.
• These broad determinants all have a major impact on the health of the
population.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK	4	– Classifying	the	determinants	of	HIV/AIDS
In	the	first	column	of	the	diagram	below,	jot	down	all	the	determinants	that	you	can	think	of	
in	relation	to	women’s	experience	of	HIV/AIDS.	
Classify	each	of	your	determinants	by	ticking	the	category	of	determinants,	into	which	it	fits
(provided	 two	examples	of	determinants	to	guide	you).	
Think	of	ways	in	which	any	of	these	categories	of	determinants	are	linked?	
Categories of determinants
Determinants
Genetic &
biological
Individual
beliefs
Socio-
cultural
Work &
living
conditions
Environ-
mental
Political,
economic,s
ocial
Anatomically,
women are more at
risk of HIV infection
than men.
√
Some religions
forbid the use of
condoms, thereby
increasing the risk of
HIV transmission.
√
Include further
determinants here.
ê
Classifying	the	Determinants	of	HIV
6/1/18 Concept	of	HP	- Rakesh	Singh
• What we are trying to illustrate here is the complexity of
the situation and the fact that many different factors
contributeto this/any health problem.
• Addressing it as health promoters therefore requires you to
be aware of the complexity of the determinants and their
inter-connectedness.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants Discussion	of	the	interconnections	between	determinants
Genetic	&	
biological	
factors
HIV, a	virus, passes	from	one	person	to	another	through	 vaginal	fluids	and	
semen,	during	sexual	intercourse,	through	 blood,	during	 childbirth,	
infected	blood,	through	 a	needle	stick	injury	or	through	IDUs.
Anatomically	women	at	more	risk,	as	larger	exposed	surface	area	of	the	
vagina	and	labia.	In	addition,	mucosal	surfaces	in	vagina	are	more	
susceptible	to	be	affected	compared	to	hardened	penile	skin.
It	is	well	documented	that	co-existing	STDs	increase	the	risk	of	HIV	
transmission	– 9	times	greater	where	one	partner	is	HIV+.	Women	are	
particularly	vulnerable	in	relation	to	this	risk,	as	their	symptoms	are	often	
non-specific	or	asymptomatic	or	might	not	be	perceived	to	be	serious	
enough	 to	seek	treatment.	STDs	in	women	thus	often	go	undetected,	
thereby	increasing	women’s	risk	of	HIV	and	giving	rise	to	infections.
INTER-CONNECTEDNESS	OF,	DETERMINANTS	OF	HIV/AIDS	EPIDEMIC	IN	RELATION	TO	WOMEN’S	
EXPERIENCE
6/1/18 Concept	of	HP	- Rakesh	Singh
Determina
nts
Discussion of the interconnections between determinants
Individual
behavioural
factors
Men and women who have many sexual partners and do not use condoms,
IDUs who share needles and syringes and HW who do not practise universal
precautions are placing themselves and others at risk of HIV transmission.
The use of alcohol and drugs... rational decisions about safer sex practices...
in relation to the HIV epidemic. For example, ... Decisions regarding using a
condom, having safer sex or in fact deciding not to have sex.
Alcohol level of violence, including sexual violence, which would then
place women in a position of risk.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants Discussion	of	the	interconnections	between	determinants	(continued)
Socio-cultural	
factors	
The	practice	of	dry	sex places	women	at	increased	risk	of	HIV	
infection	due	to	vaginal	tearing.
Religious	beliefs	that	forbid	the	use	of	condoms	might	place	
some	women	at	risk	of	HIV	infection.	
Women	are	often	blamed	or	stigmatised	for	having	a	STD	and	
thus	might	not	seek	early	treatment	for	the	infection.	
Traditional	beliefs	and	perceptions	about	masculinity,	to	
demand	sex	from	his	partner	whenever	he	desires,	or	that	
wearing	a	condom	reduces	a	male’s	sexual	power,	also	place	
women	at	risk	of	HIV.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants Discussion	of	the	interconnections	between	determinants	(continued)
Factors	around	
work	and	
living	
conditions
In	some	communities,	 women	do	not	have	equal	access	to	on-going	
training	and	tend	to	be	excluded	from	the	formal	economy.	Where	women	
have	been	able	to	access	skills	and	training,	they	have	not	always	had	the	
power	to	negotiate	equivalent	work	positions	 or	conditions	as	their	male	
colleagues.	
Having	had	less	choice	around	what	work	they	are	able	to	do,	women	
have	often	had	to	explore	other	work	options,	 such	as	sex	work,	or	in	
some	cases,	accepting	gifts,	favours	or	a	place	to	stay,	in	return	for	sex.	In	
these	situations,	where	women	are	economically	dependant	on	their	
clients/men,	they	are	likely	to	be	placed	in	a	situation	where	they	accept	
money	for	sex	without	using	a	condom,	 or	have	to	suffer	abusive	sexual	
situations.	
The	level	of	sexual	violence	is	increasing	thereby	increases	their	
vulnerability	to	HIV	infection.	
Environmental	
factors	
General	degradation	of	environment,	 for	example,	lack	of	street	lighting	
creates	an	environment	 which	is	not	safe	for	women	to	walk	in.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinan
ts
Discussion	of	the	interconnections	between	determinants	(continued)
Gender	 In	general,	women	have	less	power, not	in	a	position	 to	talk	about	and	
negotiate	safer	sex	practices.	A	woman	is	also	more	at	risk	of	violence,	abuse	
or	rejection	by	her	partner	if	she	asks	him	to	use	a	condom	.
Women	have	less	power	to	negotiate	equal	salaries	and	employment	
opportunities....more	 economically	dependent	on	men.	This	has	had	grave	
consequences	for	women	when	they	have	informed	their	partner	that	they	
are	HIV+,	as	often	the	partners	have	literally	chased	the	women	out	of	their	
homes.	Women	have	in	many	cases	had	to	leave	all	their	possessions	and	find	
accommodation	elsewhere,	which	in	turn	has	increased	their	vulnerability	to	
further	discrimination.
Lack	of	appropriate	information	places	women	in	a	less	informed	 position,	
where	they	are	unable	to	anticipate	or	identify	risky	HIV	practices.	
Information	about	human	rights	and	the	rights	of	women	has	also	not	been	
conveyed	to	young	people.......domestic	violence	and	customary	marriage	law	
of.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinan
ts
Discussion	of	the	interconnections	between	determinants	(continued)
Broader	
political,	
economic,	
and	social	
factors
Migrant	labour	system....men	often	had	multiple	sexual	partners,	
which	placed	their	primary	partner	at	risk	of	HIV	infection	when	he	
returned	home.	Women	were	left	to	work	at	home....suffer
considerable	hardship	and	poverty.	In	case	of	husbands	falling	ill	or	
dying,	women	are	left	in	an	even	more	vulnerable	position.	...to	have	
sex	in	exchange	for	food,	shelter	and	support	for	their	children.
People	are	not	aware	of	laws	which	protect	people	in	the	workplace	
and	support	anti-discriminatory	HIV/AIDS.	A	lack	of	knowledge	about	
these	laws	is	disadvantageous	to	women,	particularly	in	the	
workplace.	For	instance,	a	woman	living	with	HIV/AIDS	might	face	
discrimination	in	relation	to	how	her	colleagues	treat	her....affect	
opportunities	for	promotion	or	to	receiving	benefits	that	she	would	
normally	receive	.....	potentially	at	risk	of	experiencing	different	
levels	of	discrimination	in	terms	of	their	access	to	treatment,	care	
and	support.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants Discussion	of	the	interconnections	between	determinants	(continued)
Conflict,	
community	
instability,	
mass	
migration,	
breakdown	
in	family	
relationships
Years	of	conflict	....	instability	within	communities....disintegration	
of	support	networks	within	the	community,	the	separation	of	
families	and	increasing	numbers	of	orphans	and	street	children.	
Increased poverty	level	and	broken	relationships	place	them	at	
risk	of	HIV	infection.	
Discriminatio
n	on	the	
basis	of	
race/caste/et
hnicity	
Women	from	low	caste and	ethnic	groups	have	limited power,	
access	to	skills	development	and	the	opportunity	to	make	and	act	
on	decisions	that	impact	on	their	own	lives,	including	their	
health.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Broader political, economic and social factors are linked to other
determinants and have an influence,either negativelyor positively.
• For example:
q Migrant labour system.
q The laws did not support the principle of equity or protect against
discrimination.
q Affected the working and livingconditions ofwomen.
• Women were (and still are) not afforded the same status as men and not
given equal access to formal employment and ongoing training
opportunities. Their earning power is thus reduced, and until recently, they
have not had adequate legal protection against gender discrimination in
the workplace,or gender violence at home or in the broader community.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Further example illustrate the link between socio-cultural, gender factors and
biological factors.
In a situation where a woman is placed at risk of HIV transmission for
instance, when she is having sex with her partner, she might not have the
confidence, the skills, the economic self-sufficiency or even the choice to
insist that she is protected from the risk of HIV transmission. Coupled with
her biological susceptibility, a woman is thus placed in a significantly more
vulnerable position.
• Another example is the situation of HIV+ woman who has to make complex
decisions about motherhood.
For instance, if she decides to have a child, she risks transmitting HIV to her
child and then has to live with the consequences of this decision if her child is
HIV+. If she decides not to have a child, she might face rejection and even
potential abuse from her partner and her family. Mother-to-child
transmission also inadvertently carries with it a stigma, as women are seen as
the carriers of the disease. This reinforces a commonly held belief that
women are in fact to blame for the epidemic.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Ultimately all these determinants have a role to play in determining the
level or health status ofthe individualor community.
• Because of the relationship between all these factors, people working in
the area of Health Promotion need to consider all of the determinants
when developing and implementing an intervention in relation to women
and HIV/AIDS (any health problem), whether targeted at the general
public,at men, at the youth or at women.
6/1/18 Concept	of	HP	- Rakesh	Singh
LEVELS	OF	DETERMINANTS
• National	or	global	levels:
Related	to	broader	economic,	political	and	social	causes,	such	as	the	system,	
laws	and	regulations.
• Environmental	levels:
Related	to	the	living	and	working	environments,	and	the	natural	environment.
• Community	levels:
Related	to	community	practices,	attitudes	and	norms.
• Individual	levels:
That	are	close	to	or	part	of	an	individual,	like	those	relating	to	genetic,	
biological	and	physical	causes	and	individual	behaviour.		
6/1/18 Concept	of	HP	- Rakesh	Singh
6/1/18 Concept	of	HP	- Rakesh	Singh
• In HP, recognising how determinants are inter-linked, try to tap into and
work with the different levels.
• For example, with HIV, try to encourage young women to delay practising
sex, or to ensure that they seek immediate treatment for STDs. This is an
intervention that taps into the most individual or local level of
determinants.
• However, working with only one level of determinants could be detrimental
to our health development workin the longterm.
• For example, whilst we may be ensuring that women receive early
treatment for their STDs, we have not adequately dealt with the fact that
women also need to be provided with the skills to prevent STD infection.
For instance, they need easy access to condoms and to be able to
communicate effectivelywith their partners.
6/1/18 Concept	of	HP	- Rakesh	Singh
• As health promoters, different levels of determinants need to
be looked upon so that development of realistic health
promotion interventions can be done. Take for example the
issue of the large numbers of children with scalds and burns.
• As a health promoter working in such an institution, one
would begin to think about what role the team could play or
what would be an appropriate intervention to assist in
reducing such accidents.
6/1/18 Concept	of	HP	- Rakesh	Singh
Perhaps	asking	the	question	“Why?”	could	begin	such	a	brainstorm	
session:
• Why	are	we	seeing	so	many	children	with	burns	and	scalds?
• Is	it	because	families	are	living	in	crowded,	informal	houses	without	
adequate	cooking	and	cleaning	facilities?	
• Is	it	because	adults	are	unaware	of	the	care	and	precautions	that	need	to	
be	taken	when	using	paraffin,	gas	or	hot	water	near	children?
• Is	it	because	children	are	being	left	at	home	unsupervised	– without	
adequate	adult	supervision?	
• Is	it	because	the	accident	prevention	campaigns	have	been	inadequate?
• Is	it	because	parents	have	no	choice	but	to	leave	their	children	at	home	
as	they	need	to	go	out	and	work	and	are	unable	to	afford	regular	
childcare?	
6/1/18 Concept	of	HP	- Rakesh	Singh
• By asking the question “why?”, focus on the cause upstream and then begin
to consider how one might plan an intervention that focuses on both those
determinants that are close to the individual (like educating parents and
care-givers about safety in the home) and broader determinants like housing
regulations,access to electricity and water and economicopportunities.
• In planning an intervention, the HP team might consider setting up a joint
project with the concerned stakeholders to host an awareness raising
workshop.
• Also consider advocating small business initiative to establish child care so
that working parents can leave their children in safety.
• The team might also consider working with local businesses that are selling
gas, paraffin and cooking utensils to support a child safety campaign. For
example, they could ask shop owners to display posters about safety and to
stock and sell paraffin safety caps - a campaign which could be supported by
a local community-based radiostation.
6/1/18 Concept	of	HP	- Rakesh	Singh
Health Promotion intervention Level of
determinant
Advocate that workplaces offer adequate opportunities for workers to be supported in taking their TB
treatment.
Establish a community-based condom distribution and education programme.
Encourage TB patients to join a directly observed treatment shortcourse (DOTS) programme.
Encourage family and household members ofTB patients to come to the clinics for screening.
Advocate for the introduction oflegislation which ensures thatpeople living with HIV/AIDS are not
discriminated againstin the workplace or within the health services.
Encourage young adolescentwomen to delay practising sex.
Produce preventive HIV educational materials and facilitate lifeskills sessions for youth.
Educate children abouthow to clean their teeth regularly and correctly.
Implementan inter-sectoral programme thatencourages other developmentprojects and
organisations to work in collaboration with the health services in informing their clients abouthow to
preventTB, the signs and symptoms of TB and how to access treatment.
Advocate for an optimal level of fluoride to be maintained in the local water supply.
Ensure that men and women seek immediate treatment for STDs.
Advocate for improved quality in housing construction,so as to reduce overcrowding and improve
ventilation.
Run educational workshops on gender and violence for local councillors.
Encourage parents to adopthealthy eating routines for their children e.g.less sugar and less
frequently.
TASK 6 – Identify levels of HP interventions
Listed	below	are	some	HP	interventions	that	have	commonly	been	used	in	relation	to	the	three	health	issues	HIV/AIDS,	TB	
and	tooth	decay.	Identify	which	level	of	determinants	each	intervention	tries	to	address.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants	close	to	the	individual
• Encourage youngadolescent women to delaypractisingsex.
• Ensure that men and women seek immediate treatment for STDs.
• Encourage TB patients to join a directly observed treatment shortcourse
(DOTS) programme.
• Encourage family and household members of TB patients to come to the
clinics for screening.
• Educate children about howto clean their teeth regularlyand correctly.
• Encourage parents to adopt healthy eating routines for their children i.e.
less sugar and less frequently.
• Produce preventive HIV educational materials and facilitate lifeskills
sessions for youth.
• Establish a community-based condom distribution and education
programme.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants	that	relate	to	living	and	working	
conditions	and	the	natural	environment
• Implement an inter-sectoral programme that encourages other
development projects and organisations to work in collaboration with the
health services in informing their clients about how to prevent TB, the
signs and symptoms ofTB and howto access treatment.
• Advocate that workplaces offer adequate opportunities for workers to be
supported in takingtheir TB treatment.
6/1/18 Concept	of	HP	- Rakesh	Singh
Determinants	that	relate	to	broader	economic,	political	
and	social	causes,	such	as	systems,	laws	and	regulations
• Advocate for the introduction of legislation which ensures that people
living with HIV/AIDS are not discriminated against in the workplace or
within the health services.
• Advocate for an optimal level of fluoride to be maintained in the local
water supply.
• Advocate for improved quality in housing construction, so as to reduce
overcrowdingand improve ventilation.
6/1/18 Concept	of	HP	- Rakesh	Singh
• A single HP intervention, whilst it might be aimed at a particular set of
causes or level of determinants, might also have an impact on the other
levels of determinants.
• For example, running an educational workshop on gender and violence for
local councillors (activist/leaders) in a community is a HP intervention
aimed at increasing awareness about the issue....thus aimed at
determinants close to individual. However, it might also encourage the
participants to reflect on how safe their communityis for women.
6/1/18 Concept	of	HP	- Rakesh	Singh
• They might then lobby for changes in their environment and in local
government regulations, which try to reduce the current level of gender
violence.Such intervention might include:
q Advocatinglife-skills programmesbe run in all schools.
q Installingmore street lights in each neighbourhood.
q Training the local health workers and police force on gender issues and
gender violence.
q Increasing the allocation of resources to the police service in order that
more communitypolice officers can be employed at local police stations.
q Introducing new regulations on the handling of domestic violence by the
police.
6/1/18 Concept	of	HP	- Rakesh	Singh
Individual
L	&	W	EnvBroader
• Dividing determinants into categories is a useful analytical tool that helps
to recognise the importance of addressing the different levels of causes of
ill health.
• It is important in the process of planninga HP intervention to consider:
q firstly, how the different levels of determinants interact with one another
in causingill health or a disease,and
q secondly, how HP interventions aimed at different levels of determinants
could work alongside and complement one another.
• Generally, an intervention aimed at only one level of determinant will have
less chance of success than a Health Promotion intervention that
recognises the different levels of determinants.
6/1/18 Concept	of	HP	- Rakesh	Singh
INEQUITY	AND	HEALTH	PROMOTION
• Talking about health determinants,inevitablyraises the issue ofinequity.
• Individuals, communities and countries with the least resources unfairly
carry the burden of ill-health and mortality.
• The link between poverty and ill health is apparent where differences exist
between the different sectors of our society.
• The distribution of inequity generally reflects or falls along the lines of
race, class, gender and age.
6/1/18 Concept	of	HP	- Rakesh	Singh
• When working in the field of HP, it is important to clarify what you and
others understand health to mean, and what the causes or determinants
of ill-health are.
• It affects the way you and others view the purpose of HP, the ideals and
values upon which HP activities are based and the choices made in
developingHP interventions.
• People’s definitions ofHP embodythese ideas.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK 7 - Summarise the factors which affect your understanding of HP
Take some minutes to make a mindmap of your understanding thus far of the
factors which affect your understandingofHealth Promotion e.g. inequity.
So far we have looked at definitions, perceptions and determinants of health,
including the issue of inequity. These ideas helped us to clarify what we mean
by health. They are also crucial to understanding what we mean by Health
Promotion.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK	 8 - Analyse	definitions	of	Health	Promotion
Read	the	six	definitions	of	HP	below.	What	concept	and	model	of	health	and	what	determinants	of	health	is	
each	one	likely	to	be	based	on?	
1. “Health	Promotion	is	the	process	of	enabling	people	to	increase	control	over,	and	to	improve,	their	health.	To	reach	a	
state	of	complete	physical,	 mental	and	social	well-being,	an	individual	 or	group	must	be	able	to	identify	and	to	realize	
aspirations,	 to	satisfy	needs,	and	to	change	or	cope	with	the	environment.	Health	is	a	positive	concept	emphasizing	
social	and	personal	resources,	as	well	as	physical	capacities.	Therefore,	Health	Promotion	is	not	just	the	responsibility	of	
the	health	sector,	but	goes	beyond	healthy	life-styles	to	well-being”	(Ottawa	Charter	for	Health	Promotion,	1986).
2. “Health	promotion	is	health	education	and	related	organisational,	 political	and	economic	interventions	that	are	
designed	to	facilitate	behavioural and	environmental	changes	to	improve	health” (Green	in	Wass,	A.	1994:	39).
3. “The	terms	health	promotion	and	health	education	are	not	interchangeable.	Health	promotion	covers	all	aspects	of	
those	activities	that	seek	to	improve	the	health	status	of	individuals	 and	communities.	It	therefore	includes	both	health	
education	and	all	attempts	to	produce	environmental	and	legislative	change	conducive	to	good	health.	Put	another	
way,	health	promotion	is	concerned	with	making	healthier	choices	easier	choices” (Dennis	et	al,	in	Naidoo &	Wills,	
1994:	77).
4. “Health	Promotion	work	has	to	recognise the	prevailing	social,	economic,	political	and	cultural	context	in	which	we	all	
live.		In	recognising the	powerful	links	between	personal	and	political	issues,	we	assert	the	need	to	challenge	
inequalities	and	oppression	wherever	they	may	arise.		Health	promotion	work	seeks	to	oppose	inequity	and	oppression	
based	on	race,	ethnicity,	age,	gender,	disability,	 class,	sexual	orientation	and	religious	belief.	The	task	of	health	
promotion	is	to	enable,	facilitate	and	empower	individuals,	 groups	and	communities	in	order	that	they	gain	and	
maintain	control	of	their	lives	and	their	health.	Education	and	training	for	health	promoters	must	be	compatible	with	
these	aims” (Dr	Rachael	Dixey,	Leeds	Metropolitan	University,	UK).
5. “Health	promotion	is	the	art	and	science	of	helping	people	change	their	lifestyle	to	move	towards	a	state	of	optimal	
health” (O’Donnell	 ,M.	in	Reddy	&	Tobias,	1994:	23).
6. “Health	promotion	is	a	set	of	activities	that	aim	to	promote	healthy	living	and	to	prevent	disease	through	information,	
skills	building	and	the	provision	of	health	care” (South	African	health	and	development	worker).	
6/1/18 Concept	of	HP	- Rakesh	Singh
• Definitions (1) to (4) emphasise the Social Model of health. They support the
idea that health is a positive, holistic concept and that the health of individuals
and communities is affected by a range of determinants (social, political,
economicand cultural).
• Whilst it is generally accepted that the Ottawa Charter is strongly based within
a Social Model of Health framework, some people have interpreted the first
line of the Charter as being conservative. In other words they believe that
whilst one might be able to increase the level of control one has over one’s
health, that does not necessarily mean that one is assured of being able to live
in a good social environment.
• Definitions (5) and (6) are somewhat narrower and seem to imply a focus on
promoting the health of individuals. They emphasise biological and individual
behavioural determinants.
6/1/18 Concept	of	HP	- Rakesh	Singh
Some of the common themes which underpin the first three definitions are:
• HP is a process - it does not happen overnight, but is rather a longer-term set
of sustained activities and interventions.
• HP aims to improve the health status of individuals and communities and
enable them to gain increased control over their health.
• Based on the philosophyofself-empowerment.
• Entails different strategies, such as providing information and building skills, to
developingpolicyand legislation.
• HP is not equivalentto health education,but encompasses it.
• Involves inter-sectoral action and workingin partnershipwith other sectors.
6/1/18 Concept	of	HP	- Rakesh	Singh
• The last two definitions of HP are considerably more individualistic in their
emphasis and would most likely be focused on working towards attitude
and behaviour change within a health care setting.
• They assume that individuals have considerable influence over their
environment, and that a healthy outcome would automatically result from
the changes made in behaviour.
6/1/18 Concept	of	HP	- Rakesh	Singh
• One of the challenges that a health promoter may be faced with is
working in an environment where different parties hold different
understandings ofHP.
• Our conceptualisations affect our responses to health problems and
strategies for HP; health promoters need to develop a way of dealing with
these differences.
The next task offers you an opportunity to prepare yourself for this
problem.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK 9 – Managing different understandings of Health Promotion
Imagine that you are going to set up a HP project involving health colleagues,
other professionals (such as teachers and engineers) and community members.
It is likely that everyone does not share the same understanding of health and
of the role that determinants play in influencing health or ill health. People are
also likely to have had different experiences, and thus have different levels of
familiaritywith the concept of HP.
a) How would this affect the project?
b) How would you cope with this situation?
c) What would you do at the start of the project?
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
• Universally, it is unlikely that a single concept of health, which is
acceptable to all, will ever be developed.
• Instead,diverse and competingdefinitions are inevitable.
• This can lead to confusion, misunderstanding and lack of true co-operation
when settingup a HP project.
• Ultimatelythis can undermine the success of the project.
• To address these problems and to work successfully with colleagues and
the community, it is important for everyone involved to share their
understandingofhealth and HP.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd..
• You could suggest that this be done as part of an ice-breaker or introductory
exercise in your first meeting or workshop.
• You could then reach consensus on the main elements of these definitions
through group discussion.
• This awareness-raising exercise could be the first step towards establishing a
good working relationship and forging a closer understanding of what HP
means for your team members.
• It might also allow the group to start thinking about the appropriate level of
determinants to target the HP intervention.
6/1/18 Concept	of	HP	- Rakesh	Singh
AIM GOAL
Health Promotion
A process of
enabling people to
increase control
over the
determinants of
Health and thereby
improve health
It embraces actions
•Directed at strengthening
the skills & capacities of
individuals so that they can
change and cope with the
environment.
•Directed towards changing
social, environmental &
economic conditions to
alleviate their negative impact
on public or collective health
and individual health.
PRINCIPLES
& METHODS
•Participation is essential to sustain health promotion
•Health Promotion action is not the responsibility of the health sector alone-it
involves all sectors, systems and structures that govern our social, economic and
physical environment.
6/1/18
Concept	of	HP	- Rakesh	Singh
TASK 10 – Reflect on your initial definitionof Health Promotion
Look	back	at	your	definition	of	health	promotion	in	Task	2.	Are	you	still	
comfortable	with	this	definition?	If	you	are,	that’s	fine!	However,	if	
you	feel	that	you	have	a	different	understanding	of	Health	Promotion	
now,	try	rewriting	your	original	definition	to	fit	with	your	new	
thinking.
6/1/18 Concept	of	HP	- Rakesh	Singh
• By now, you probably have a fairly strong sense of how our values,
experiences and our own critical perspectives influence the way we
conceptualise Health Promotion,and therefore the strategies we use.
• In order to develop our understanding even further, we need to look at
the history of the Health Promotion Movement to find out where Health
Promotion originated.
6/1/18 Concept	of	HP	- Rakesh	Singh
Forerunners	of	Health	Promotion
6/1/18 Concept	of	HP	- Rakesh	Singh
AN	OVERVIEW	OF	THE	HISTORY	OF	
HEALTH	PROMOTION
TASK 11 – Clarify some terms
Historical	accounts	often	describe	particular	events,	gatherings	
of	people,	documents,	laws	etc	as	landmarks,	milestones and	
watersheds.	What	do	each	of	these	three	terms	mean,	in	their	
original	usage	or	literally	and	in	everyday	usage?		
6/1/18 Concept	of	HP	- Rakesh	Singh
• A landmark literally means an object that is easily seen in a landscape. In
everydayuse it means an important historicalevent.
• A milestone literally referred to a stone that used to be placed beside the
road to mark the distance between towns. In everyday use it also means
an importantevent in life or history.
• A watershed literally describes a line of high land from which streams flow
down on all sides. In everyday use it means a turning point in the course of
events.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK 12 – Think about the history and forerunners of Health Promotion
a)What do you know about the history of Health Promotion? Where, when,
how and why did it start? What were the landmark or watershed dates,
events and documents associated with it? Jot down any knowledge you
have in a mind map like the one below.
b)The origins of the term Health Promotion is linked to activities that took
place around the 19th centuryin Europe.Whyis this?
c)Can you think of any examples of health promoting activities which took
place earlier in history,and in places other than Europe?
History of Health
Promotion
6/1/18 Concept	of	HP	- Rakesh	Singh
a) Your mind map will be helpful in reminding you that you already have some
prior knowledge about the topic
b) 1. The term Health Promotion is associated with 19th century Europe
because this was the first time in more recent history when public health
concerns were officiallyrecognised and seen to be of national importance.
2. It is interesting to note that many of the popular Health Promotion texts
start discussing the history of Health Promotion from this period (i.e. the
19th century) onwards and focus exclusively on public health legislation and
reform that was implemented in Europe,Britain or North America.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
3. Very few writers begin discussing the history of Health Promotion by
using examples of Health Promotion interventions from earlier centuries or
describing traditional indigenous practices or beliefs about health and
disease.
4. It is an interesting bias and reflects the focus of the authors on
documenting events in their own countries for the interest of their first
world readers.
5. It is also perhaps a reflection on the lack of documentation about
indigenous health practices which were considered by many in the colonial
era to be unscientific.
6. This was partly because practices were transferred from one generation
to the next through oral tradition and oral communication rather than the
written word.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
c) However, histories of Public Health show that some form of collective public
health measures have always been implemented by societies. Strategies to
promote health would have inevitably formed a part of these measures,
although these would not have been called HP.
Examples include:
-The Roman publicbaths.
-Roman laws governing burial of the dead and regulating dangerous animals
and unsound goods.
-The regulation ofprostitution in Ancient Rome and Greece.
-Inoculation against smallpoxin India and China before the Christianera.
-The isolation of people with leprosy in Europe in the Middle Ages (5-15th
Century.
-The quarantiningofships by the Venetians (Italy).
6/1/18 Concept	of	HP	- Rakesh	Singh
• Western concept of public health and concepts of health and disease
would have had little relevance or significance to the indigenous people
as hunter gatherers they did not have the Public Health problems
associated with permanent settlements.
• Traditional healers use of natural products for healing was part of the
indigenous practice which had little connection to European concepts of
Public Health.
• The world including developing nations have a rich history of indigenous
healing. To what extent has this indigenous practice been incorporated
into the recordingof our local Health Promotion history?
6/1/18 Concept	of	HP	- Rakesh	Singh
Health	Promotion	Era
Milestones	in	the	development	of	health	promotion
6/1/18 Concept	of	HP	- Rakesh	Singh
The Health Promotion Movement
The	four	key	movements	or	eras	affecting	HP:	
1. Early	Public	Health	Movement	i.e.	the	concern	with	environmental	
conditions.
2. Medical	Era	i.e.	the	belief	that	medicine	had	all	the	answers.
3. Health	Education	Era	i.e.	that	medicine	does	not	have	all	the	answers.
4. New	Public	Health	Movement/Health	Promotion	Era	i.e.	that	Health	
Education	does	not	solve	everything	and	can	result	in	blaming	the	
victim.	
6/1/18 Concept	of	HP	- Rakesh	Singh
DIFFERENTIATING	HEALTH	EDUCATION	
AND	HEALTH	PROMOTION
• Since the mid-1980’s, there has been considerable debate
about the difference between Health Promotion and Health
Education.
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK 12 – List the differences between Health Education and
Health Promotion
Jot	down	the	main	differences	between	Health	Education	and	Health	
Promotion	in	terms	of	their
•Aims.
•Activities	and	strategies.	
6/1/18 Concept	of	HP	- Rakesh	Singh
• Both have the same aim, “to improve or protect health”. However, the
scope of their activity varies.
• In the case of HE, most activity centres on providing learning opportunities
for individuals and communities so that they are able to voluntarily
change their behaviour.
• They acquire information and skills to help them initiate a change that
enhances their well-beingand their health.
• HP activity is much broader and includes both HE
And:
1. The provisionofpreventative healthservices.
2. Measures to protect the physical environment and make it conducive to
health
3. The mobilisationofcommunityresources.
4. The implementationoforganisational policies which promote health.
5. Economicand regulatoryactivities.
6/1/18 Concept	of	HP	- Rakesh	Singh
HP	Vs	HE
• The two concepts,HE and HP are symbioticstrategies.
• A key feature that distinguishes HP from HP is that HP involves environmental
and political action.
• Similarly, Tones and Tilford (2001) have suggested that it is possible to distil
the concept of HP into an essential formula:
Health Promotion = Health Education x HealthyPublicPolicy
• HP is the product of both HE and HPP.
• The multiplication sign x literally means to add a given amount several times
over.
• Here the given amount is HE which is added as manytimes over as HPP.
• In other words, when HE and HPP are multiplied, they produce a far greater
effect than just the sum of the two. HE and HPP - if implemented together
produce an effect that is far greater than the individual parts.
• This formula serves to illustrate how central both Health Education and policy
are to the achievement of individual, community and national health status,
and how symbiotic or inter-connected the relationship is between Health
Education and the broader activityofHealth Promotion.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd..
• Some people viewed HE in a rather stereotypical way, reflecting a narrow
field of activityand focusingon the individual.
• HP, on the other hand has been positioned as the more politically correct
approach to challenginghealth status.
6/1/18 Concept	of	HP	- Rakesh	Singh
Health	Promotion	is	thus	seen	as	the	umbrella term	that	includes	
a	whole	range	of	activities,	such	as	policy	development,	
environmental	or	social	action	and	organisational	development.
6/1/18
Concept	of	HP	- Rakesh	Singh
Approaches	to	Health	Education	
• HE is seen as a way of providing the public and in many cases risk groups
with information; this information is intended to motivate them to change
the behaviour that placed them at risk of developing a particular disease
or set of diseases.
• Diverse approaches to HE have emerged over the last century:
q The two most common- preventive approach and the educational
approach.
q A third approach has also been implemented - the empowerment
approach.
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Preventive	Approach
• Aims to provide individuals with knowledge, facilitate a change in attitude and, if
successful, to galvanize the individual into action or into the practice of
preventive behaviours.
• The approach supports the use of a variety of persuasive communication
strategies, for example, mass media campaigns, or individual educational
sessions at a local clinic, to influence behaviour change.
• This approach has been criticised for assuming that knowledge leads to a change
in attitude.
Take the issue of a healthy diet for example: whilst I know that cream cakes and
donuts are unhealthy for me, I have not eliminated them from my diet. The same
could be said for smoking. As a health worker, I know smoking is bad for me and
that it has a negative impact on my health. However I am not planning to give up
smoking. Both examples illustrate that the relationship between knowledge,
attitude and behaviour change is not straightforward.
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Educational	Approach
• Aims to provide individuals with understanding and knowledge, facilitate a
process of belief and value clarification, and develop and practise the skills to
make informed decisions.
• A key component of this approach is the recognition given to the value of
voluntarism, i.e. that individuals should be free to make their own decisions,
either now or at some future time, about their choice of action.
• This kind of approach would be suitable as a basis for running workshops
where individuals are or will be faced with havingto make a choice.
• For example, the approach could be used in the various stages of a smoking
cessation programme or in a dieting programme. It often includes a series of
value clarification workshops.
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Empowerment	Approach
• This approach supports the idea of providing individuals with an opportunity
to critically reflect upon their environment, as they acquire knowledge, to
clarify their values and develop skills.
• This enables them to maximise their chances of managing the
environmental constraints - constraints over which individuals might find it
difficult to exercise some degree of control, if they did not have adequate
life skills.
• This approach is very much a bottom-up approach and is like the process of
communitydevelopment -with the health promoter as facilitator.
• An example- health promoter working with teachers to develop programmes
aimed at building the self-esteem of young girls, so that they are able to
actively participate in their studies and to enter into relationships with
greater self-confidence.
6/1/18 Concept	of	HP	- Rakesh	Singh
• HE models have been subject to a considerable amountofcriticism.
• Concerns have been raised about their individualistic approach and their
tendencytowards blamingthe victim.
• For instance, how empowered are individuals to receive and to act on health
education messages, when the context in which they live does not support
or allowfor the necessarybehaviour change?
• For example, it might be difficult for a teenager to stop smoking when
adverts glamorise smoking and there is pressure on young people to smoke
in order to fit into their peer group.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Although	HE	has	achieved	some	success	in	changing	lifestyle,	it	has	been	
realised	that	changes	in	individual	behaviour would	not	bring	about	the	
necessary	improvements	or	changes	that	are	required	to	change	patterns	
of	ill	health	or	disease.	
• Many	of	the	changes	that	were	required	were	beyond	the	power	of	the	
individual.	
• This	is	where	the	ideas	of	the	New	Public	Health	and	Health	Promotion	
arose.	
• Let	us	now	take	a	few	steps	back	and	consider	how	this	transition	came	
about	and	what	other	influences	have	shaped	the	course	of	Health	
Promotion	as	we	know	it	today.
6/1/18 Concept	of	HP	- Rakesh	Singh
HISTORY	OF	THE	HEALTH	PROMOTION
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Early	Public	Health	Movement	in	Europe
• In	Northern	Europe,	the	Industrial	Revolution	(late	18th century	in	Britain),	
and	the	growing	popularity	and	attraction	of	cities	resulted	in	massive	
changes	in	population	patterns	and	in	the	physical	environment	in	which	
people	lived.	
• However,	this	rapid	industrialisation	also	brought	with	it	disease	and	social	
dislocation	– the	disintegration	of	family	and	social	structures.
• In	Britain,	the	overcrowded	and	unsanitary	living	conditions	of	the	poor,	
coupled	with	the	rise	of	cholera	and	typhoid	as	major	causes	of	death,	
placed	pressure	on	the	government	to	introduce	reforms	or	legislation	to	
promote	public	health.	
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• In	1842,	Edwin	Chadwick,	responsible	for	leading	a	“Health	of	Towns	Commission”	
and	advocating	for	the	first	public	health	reforms,	suggested	that	the	ill	health	
experienced	by	the	poor	was	a	result	of	poor	housing,	sanitation	and	unclean	
water.	
• His	efforts	resulted	in	the	1848	Public	Health	Act,	which	gave	local	authorities	the	
powers	to	remedy	unsanitary	conditions	and	to	require	adequate	drainage	and	
sanitation	in	towns.
• It	was	around	this	time	(1854),	John	Snow	discovered	that	cholera	was	a	
waterborne	disease,	by	tracing	an	outbreak	to	a	water	pump	in	Broad	Street,	Soho,	
London.	When	use	of	the	water	pump	was	stopped,	the	outbreak	stopped.	
• Experiences	such	as	these,	together	with	public	health	legislation	led	to	the	
appointment	of	Medical	Officers	of	Health	by	local	authorities,	to	enforce	public	
health	legislation	and	advise	on	appropriate	measures.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Opinions	differ	about	whether	this	early	public	health	movement	evolved	
out	of	a	“desire	to	control	disease	and	the	poor who	were	seen	to	be	the	
cause	of	it,	rather	than	by	a	more	altruistic	desire	to	make	a	society	a	
fairer	place”.
• Some	theorists	believe	that	the	sanitary	reforms	that	were	introduced	
during	this	time	were	more	about	ensuring	that	the	workforce	was	
economically	active	and	could	support	an	efficient	capitalist	economy	than	
about	the	redistribution	of	resources	and	better	living	conditions	for	the	
poor.
• Altruism	or	control	of	the	poor???	
6/1/18 Concept	of	HP	- Rakesh	Singh
The	rise	in	popularity	of	the	Medical	Model
• Motivations	aside,	at	the	end	of	the	nineteenth	century,	the	emphasis	on	
improving	environmental	and	social	conditions	in	order	to	prevent	ill-
health	was	overshadowed	by	the	rising	popularity	and	investment	in	a	
medical	(or	curative)	approach	to	tackling	ill-health.	
• “As	the	most	pressing	environmental	problems	were	brought	under	
control,	action	to	improve	the	health	of	the	population	moved	on	first	to	
personal	preventative	medical	services,	such	as	immunization	and	family	
planning,	and	later	to	a	range	of	other	initiatives	including	the	
development	of	community	and	school	nursing	and	school	health	services”.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd..
• Public	health	activity	then	entered	a	therapeutic	era	from	the	1930’s,	with	
the	advent	of	insulin	(which	treats	diabetes)	and	simple	antibiotics.
• Historically,	this	period	was	also	characterised	by	“a	weakening	of	
departments	of	public	health	and	a	shift	of	power	and	resources	to	
hospital-based	services	and	particularly	those	based	in	teaching	hospitals”.
• Underlying	this	therapeutic	orientation	was	an	“…	implicit	assumption	
that	magic	bullets	could	be	provided	by	the	pharmaceutical	industry	for	all	
conditions”
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• This	trend	– that	of	placing	greater	emphasis	and	value	on	scientific	
medicine	rather	than	on	social,	political	and	environmental	measures	to	
treat	and	prevent	ill-health	continued	until	the	early	1970’s.	
• You	will	recall	that	this	is	a	medical	model	approach	as	opposed	to	a	social	
or	Public	Health	model	approach.	
• During	this	era,	medical	advances	claimed	much	of	the	credit	for	
extending	life	expectancy.	
• After	the	Second	World	War	“medical	progress	seemed	to	promise	that	it	
would	eventually	be	able	to	cure	most	diseases”.	
6/1/18 Concept	of	HP	- Rakesh	Singh
Questioning	the	Medical	Model	
• The	social	climate	of	the	1960s	and	1970s	was	characterised	by	protest,	
activism	and	challenging	of	the	status	quo	or	existing	conditions.	
• Examples	are	the	Vietnam	War,	issues	of	gender	equality	and	the	Women’s	
Movement	which	were	raised	and	protested	about	in	public.	
• In	addition,	during	the	early	1970s,	many	countries	were	experiencing	a	
crisis	in	health	care	costs.		
• People	began	to	consider	that	whilst	medicine	might	be	good	against	acute	
illnesses	like	TB	or	pneumonia,	it	did	not	appear	to	have	much	to	offer	in	
other	areas	such	as	cancer.	
• The	rates	of	cancer	were	still	the	same	and	there	was	still	no	cure	for	the	
disease.	
• Thus,	value	or	returns	from	the	investment	in	medical	technology	appeared	
to	be	decreasing.	
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Studying	the	growth	of	the	population	in	England	and	Wales,	showed	that,	
apart	from	the	smallpox	vaccination,	immunisation	or	medical	therapies	
were	unlikely	to	have	had	a			significant	impact	on	mortality	in	the	19th and	
20th centuries.	
• Further,	mortality	was	in	fact	declining	before	effective	medical	
interventions	were	available.	
• When	ranked	the	major	contributing	factors	to	improvements	in	health	in	
order	of	importance....	“…limitation	in	family	size	(a	behavioural	change),	
increase	in	food	supplies	and	a	healthier	physical	environment	
(environmental	influences)	and	specific	preventive	and	therapeutic	
measures”.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Interventions from government authorities were critical in enabling health
to be improved.
• Collectively, it was established that there was importance of general
standards of living and of state intervention in improving the health of
populations - crucial ideas underpinning the new Public Health
Movement.
6/1/18 Concept	of	HP	- Rakesh	Singh
The	New	Public	Health	Movement
• The Lalonde Report is the first major landmark in what came to be known as
the New Public Health era.
• In 1974, the Canadian Minister of National Health and Welfare, Marc
Lalonde,publisheda report entitled A New Perspective on the Health.
• This report suggested that greater emphasis should be attributed to the
environment and to behavioural factors as causes of disease and death,
rather than biophysical characteristics.
• This was a major change from the Medical Model:in what way did it differ?
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• The Lalonde report described four health fields as having an influence on
health and illness:
1. Medicine and health care services.
2. Lifestyle or behavioural factors.
3. The environment.
4. Human biology.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Also proposed that critical improvements within the environment,
combined with changes in behaviour could lead to significant reductions in
morbidityand mortality.
• This report is viewed by some as a highly significant watershed in that it
“… signalled the turning point in efforts to rediscover public health in
developed countries”. It did so by proposing that policies focus more on
the preventionofillness than on treatment and cure.
• Many people consider this report as marking the beginning of the New
Public Health Movement.
6/1/18 Concept	of	HP	- Rakesh	Singh
A focus on lifestyle
• Even though the Report broke with the Medical Model, the particular
focus on individual behaviour or lifestyle was seen by some as cause for
concern.
• The focus was criticised because it was seen as narrow, failing to take into
account the impact of social forces (e.g. peer influences, commercial
marketing and the price of commodities)on behavioural choices.
• As a result, the approach tended to ignore an individual’s social
environment,or the context in which decisions were being made.
• Greater emphasis was placed on individual responsibility. This led to the
idea of self-imposed risk in relation to health.
• In other words, people placed themselves at risk of ill-health through their
choice of behaviour, e.g. drinking alcohol, taking drugs, getting pregnant
unintentionallyand catchingSTDs.
Contd…
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• HP	programmes	based	on	the	approach	of	the	Lalonde Report	would	have	
focused	on	persuading	people	to	change	their	health-related	behaviour,	which	
placed	them	at	risk	of	disease.	
• This	focus	on	lifestyle was	characteristic	of	the	1970s	and	brought	about	
different	approaches	to	creating	change	in	individual	behaviours.	
• These	approaches	drew	almost	exclusively	on	psychological	theory,	with	little	
regard	for	the	individual’s	social	and	economic	circumstances.	
• Well	known	behaviour	change	models	such	as	the	Health	Belief	Model,	the	
Theory	of	Reasoned	Action	and	the	Social	Learning	Theory	were	developed	
during	this	time.	
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Parallel with this behavioural approach to Health Promotion, there was an
increasing understanding of the structural causes of illness and health: in
other words, those who did not subscribe to the ideas of Lalonde’s
approach were developing one which took account of those causes that fell
outside the control ofthe individual.
• In line with this understanding, two significant WHO events occurred in the
late 1970’s, which shaped the development ofHealth Promotion.
q World Health Organisation: Global Strategy for Health for All by the Year
2000 (1977), and the International Conference on Primary Health Care,
Alma-Ata (1978)
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• In 1977, 30th WHA decided that the main health-related goal of
governments and WHO in the coming decades should be directed at
ensuring that all the people of the world attain a level of health that
would permit them to lead socially and economically productive lives
(Global Strategyfor Health for All by the Year 2000 -HFA 2000).
• This global strategy was adopted in 1981 by 34th WHA and thereby
accepted as WHO policy.
• Member states of the WHO were invited to formulate their national
policies, strategies and plans of action for attaining this goal and to act
collectivelyin formulatingregional and global strategies.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• The significant feature of HFA 2000 was the recognition that the main
determinants of health lay outside the health sector - namely food, water,
sanitation,housing,employment etc.
• This implied a global movement in which inequities between as well as within
countries could be reduced.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• In 1978, the International Conference on Primary Health Care at Alma-Ata
defined the key to achievingthe goal of HFA 2000 as Primary Health Care.
• The Declaration on Primary Health Care at Alma-Ata was an important
milestone in the development ofcurrent concept of Health Promotion.
• In the early 1980’s, some of the key principles of the Primary Health Care
approach such as equity, community participation, a focus on prevention
and the need for multi-sectoral activity, were being incorporated into
international discussions about a new concept – that of Health Promotion.
• Community participation or community involvement in health
development is central to any discussion which focuses on Health
Promotion.
6/1/18 Concept	of	HP	- Rakesh	Singh
Principles	of	HP
• The	WHO	later	convened	two	working	groups	that	focused	on	Health	
Promotion.	
• First,	in	1984,	a	WHO	working	group	met	in	Copenhagen	and	drew	up	an	
outline	of	the	most	important	issues	facing	the	development	of	Health	
Promotion	policies	and	programmes.	Arising	from	this,	the	WHO	made	
explicit	five	key	principles	for	Health	Promotion:	
1. Involves	the	population	as	a	whole	in	the	context	of	their	everyday	lives,	
rather	than	focusing	on	people	at	risk	of	specific	diseases.	
2. Directed	towards	action	on	the	causes	or	determinants	of	health,	to	ensure	
that	the	total	environment,	which	is	beyond	the	control	of	individuals,	is	
conducive	to	health.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
3. Combines	diverse	but	complementary	methods	or	approaches,	including	
communication,	education,	legislation,	fiscal	measures,	organisational	
change,	community	development	and	spontaneous	local	activities	
against	health	hazards.
4. Aims	particularly	at	effective	public	participation,	supporting	the	
principle	of	self-help	movements	and	encouraging	people	to	find	their	
own	ways	of	managing	the	health	of	their	community.
5. While	Health	Promotion	is	basically	an	activity	in	the	health	and	social	
fields	and	not	a	medical	service,	health	professionals,	particularly	in	
Primary	Health	Care	have	an	important	role	in	nurturing	and	enabling	
Health	Promotion.	
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• In relation to these principles, the WHO noted that improvements in
lifestyles, environmental conditions and health care will have little effect if
fundamentalconditions are not met.
• These conditions include peace or freedom from war, equality, satisfaction
of basic needs,political commitment and publicsupport.
6/1/18 Concept	of	HP	- Rakesh	Singh
International	Conference	on	Health	Promotion,	
Ottawa,	Ontario,	Canada	(1986)
• Conference produced a critical document - the Ottawa Charter for Health
Promotion.
• Many of the principles outlined by the WHO in their earlier working group
were developed further in the Ottawa Charter.
6/1/18 Concept	of	HP	- Rakesh	Singh
6/1/18 Concept	of	HP	- Rakesh	Singh
• The Ottawa Charter outlined five areas in which Health Promotion action
should be directed:
1. Buildinghealthypublicpolicy.
2. Creatingsupportive environments.
3. Strengtheningcommunityaction.
4. Developingpersonal skills.
5. Re-orientinghealth services.
• It identified three ways (or strategies) in which health could be promoted,
namelythrough:
1. Advocacy
2. Enablement
3. Mediation
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• The Charter notes that HP strategies and programmes should be adapted
to the local needs and that the differing social, cultural and economic
systems within countries and regions should be taken into account when
developingprogrammes.
• The Conference tended to focus more on the needs of the industrialised
countries,rather than developingcountries.
• Alma Ata had a sense of abundance about it, Ottawa was characterised by
restraint, reflecting the climate of the times in which the Charter was
drafted.
• The Charter has however been used worldwide as the basic framework
around which Health Promotion activities are planned and is regarded as
“...something of a mantra [or a set of guidelines] for health promotion
workers”.
6/1/18 Concept	of	HP	- Rakesh	Singh
Pre-requisites	of	Health	(Promotion)	
1. Peace
2. Shelter
3. Education
4. Food
5. Income
6. A stable eco-system
7. Sustainable resources
8. Social justice
9. Equity
6/1/18 Concept	of	HP	- Rakesh	Singh
TASK	13	– Based	on	Ottawa	Charter	for	Health	Promotion
a) Why	is	it	important	for	health	workers	in	developing	countries	to	be	
aware	of	the	prerequisites	for	health?	
b) How	are	these	prerequisites	for	health	linked	to	the	principle	of	
inter-sectoral collaboration	proposed	in	the	declaration	of	Alma	
Ata?
c) What	do	the	verbs	to	“advocate”,	“enable”	and	“mediate”	mean?	
d) What	are	some	practical	everyday	examples	of	these	three	
strategies	or	tools	of	Heath	Promotion	– “advocacy”,	“enablement”	and	
“mediation”?
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
• The Charter is based on the belief that a secure foundation in society- the
fundamental conditions of “peace, shelter, education, food, income, a stable
eco-system, sustainable resources, social justice and equity” - are
prerequisites for health improvement.
• Working in the context of a developing country, it is important for HP workers
to reflect on the extent to which such prerequisites exist, and how these
might affect the success or the outcome of HP interventions.
• These prerequisites are linked to the principle of inter-sectoral collaboration,
which is a way of helping to secure these conditions. This connection is
summarised in the followingquote:
“Health cannot be achieved by the health sector alone. In developing
countries in particular, economic development, anti-poverty measures, food
production, water, sanitation, housing, environmental protection and
education all contribute to health and have the same goal of human
development”(WHO-UNICEF, 1978: 40).
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• To	advocate	means	to	speak	in	favour	of	something	or	to	recommend	it.	
• To	enable	means	to	provide	the	means	or	the	ability	to	do	something.	
• To	mediate	means	to	negotiate	between	opposing	sides.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
Examples of advocacy include:
• Petitions drawn up by groups of people in response to a particular issue
e.g. the lack of adequate protection provided to a community by the
police service or the number of rapes occurring within a region or country.
• Demonstrations e.g. a group of bus drivers and owners protesting outside
of parliament about current transport legislation that restricts their
business.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
Examples of enablement include:
• Trainingprogrammes and workshops.
• Representative meetings e.g. all stakeholders involved in running a health
clinic.
Examples of mediation include:
• Reaching agreement around co-ordinated action e.g. where the Health
and Education Departments work together to develop health promoting
schools within a local district.
• Two parties coming to an agreement whereby individual interests are set
aside in the interests of the health of a community e.g. after a meeting
with the health department, a trucking company agrees to review their
policy around the length of time drivers spend away from home and
agrees to support an educational intervention for their long-distance
drivers.
6/1/18 Concept	of	HP	- Rakesh	Singh
Strategies	of	health	promotion
Advocacy
• Involves a process of pressurisingor pushingfor change.
• Usually aimed at changing policies, laws or regulatory measures that either
work against the development of optimal health or fail to protect the health
of individuals and communities.
• Often seen as a process of representing the rights or needs of marginalised
groups such as street children, sex workers, people suffering from a
particular health condition,or poor communities.
• Collaborative process, gives a voice to the needs of a community and brings
these needs to the attention of appropriate decision-makers, or those that
have the power to change the unhealthy policies.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Communication is an important component ofthe advocacy process.
• Communication strategies include:
1. Interacting and engaging with the mass media, so as to profile the
campaign and shape public debate around the problem that the campaign
is addressing.
2. Producing and distributing educational media about the issue or the
problem.
3. Networking with others in order to develop support for the campaign
which often gives rise to the development ofcoalitions.
6/1/18 Concept	of	HP	- Rakesh	Singh
ADVOCACY	VS	LOBBYING???
6/1/18 Concept	of	HP	- Rakesh	Singh
Advocacy	VS	Lobbying
• Advocacy is generally used to describe the broad range of activities that
one would do to influence change.
• Lobbying refers to the specific work one would do to influence key
decision-makers (like parliamentarians and local councillors).
• It is suggested that the word lobbying came to be used like this because
advocates would spend many an hour waiting in the parliamentary lobby
in order to catch up and meet with parliamentarians!
6/1/18 Concept	of	HP	- Rakesh	Singh
Enablement
• Enablement is a wayof workingwith others in a participative manner.
• It is a process that encourages people to reflect on their own experiences
and facilitates a process of learning and skills-building, which people can
applyto their everydaylives.
• The Ottawa Charter links enablement with equity(or fairness)in health.
• For example, if we develop capacity or increase the skills of individuals or
groups, be they health workers or members of the community, they will
have more power to control the factors that determine their health.
6/1/18 Concept	of	HP	- Rakesh	Singh
Mediation
• Mediation is a way of coming to an agreement, of seeking reconciliation,
of settingaside individualinterestsand negotiatinga common goal.
• The Charter links the term mediation to co-ordinated action between
different players – a concept that is often referred to when we talk about
inter-sectoral action.
• The motivation behind working together is that co-operation produces
greater output than competition.
6/1/18 Concept	of	HP	- Rakesh	Singh
6/1/18 Concept	of	HP	- Rakesh	Singh
ASSIGNMENT 1 – Analyse HP projects in terms of the Ottawa Charter
Look at the five areas of action and the three strategies in the Ottawa
Charter.
Think about a project in your own context, and analyse and Classify each
project or initiative intothe five areas of action and the three strategies.
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
• In reality, it is difficult to distinguish into which particular action area a
Health Promotion project falls or which particular strategy you are using or
working with as a health promoter.
• Inevitably the processes involved in one action area overlap with the work
we do in another other area.
• Very often we find we are working with all three strategies.
• For example, in the process of developing a community campaign
(advocacy), we often have to develop people’s skills or capacity in a
particular area (enablement) and to facilitate agreement between the
different parties involved in the campaign issue (mediation).
• The important point in this exercise is to realise that for a Health Promotion
project to be successful, it cannot work exclusively in one action area alone.
There is a greater chance of change occurring if consideration is given to
working across a range of areas of action.
6/1/18 Concept	of	HP	- Rakesh	Singh
• Following the development of the Ottawa Charter, the WHO convened a
second Working Group on Health Promotion in Developing Countries in
Geneva in October 1989.
• The task of this group was to explore the application of Health Promotion
concepts and strategies to developing countries and to recommend
specific steps for translatingthese into action.
6/1/18 Concept	of	HP	- Rakesh	Singh
A	CALL	FOR	ACTION
• The summary statement produced by the working group meeting
(convened by the WHO in 1989) for developing countries is called A Call for
Action: Promoting Health in Developing Countries (WHO, 1991). It focuses
on four main themes:
1. Issues (which are often in the form of challenges), that need to be
considered in the field of Health Promotion.
2. The importance ofworking together to develop healthypublicpolicies.
3. Supportinggrass-roots strategies.
4. Strengthening political commitment to and national capability for Health
Promotion.
• The statement proposed that: “Immediate and sustained action is called for
now in all nations,to move health promotion from concept to reality”.
• Although developed over two decades ago, this document still provides a
useful overview of some of the key issues that need to be considered in
relation to Health Promotion in a developingcontext.
6/1/18 Concept	of	HP	- Rakesh	Singh
6/1/18 Concept	of	HP	- Rakesh	Singh
The	HP	Emblem
• Represents	a	circle	with	3	wings
• The	main	graphic	elements	of	the	HP	logo	are:
1. one	outside	circle,
2. one	round	spot	within	the	circle,	and
3. three	wings	that	originate	from	this	inner	spot,	one	of	which	is	breaking	the	
outside	circle.
a. The	outside	circle,	originally	in	red	colour,	is	representing	 the	goal	of	“Building	
Healthy	Public	Policies”,	therefore	symbolising the	need	for	policies	to	“hold	
things	together”.	This	circle	is	encompassing	the	three	wings,	symbolising the	
need	to	address	all	five	key	action	areas	of	health	promotion	 in	an	integrated	
and	complementary	manner.
b. The	round	spot	within	the	circle	stands	for	the	three	basic	strategies	for	health	
promotion,	 “enabling,	mediating,	and	advocacy”
c. The	three	wings	represent	the	five	key	action	areas	for	health	promotion	 that	
were	identified	in	the	Ottawa	Charter	for	Health	Promotion	 in	1986	and	were	
reconfirmed	in	the	Jakarta	Declaration	on	Leading	Health	Promotion	 into	the	
21st	Century	in	1997.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
More specifically:
• The upper wing represents that action is needed to “strengthen community
action” and to “develop personal skills”. This wing is breaking the circle to
symbolise that society and communities as well as individuals are constantly
changing and, therefore, the policy sphere has to constantly react and
develop to reflect these changes: a “HealthyPublic Policy” is needed;
• The middle wing represents that action is needed to “create supportive
environmentsfor health”
• The bottom wing represents that action is needed to “reorient health
services” towards preventingdiseases and promotinghealth.
• Overall, the logo visualises the idea that HP is a comprehensive, multi-
strategyapproach.
6/1/18 Concept	of	HP	- Rakesh	Singh
Recent	Developments	in	Health	Promotion
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Second	International	Health	Promotion	
Conference
• Held	in	Adelaide,	Australia	(1988).	
• Focused	on	the	theme	of	healthy	public	policy.	
• At	this	conference,	the	DG	of	the	WHO	at	that	time	explained	that	the	
main	aim	of	developing	healthy	public	policies	was	to	create	the	
preconditions	for	healthy	living	through:
q closing	the	gap	between	social	groups	and	between	nations;
q broadening	people’s	choices	to	make	healthy	their	choices	the	easiest	and	
most	possible,	and
q ensuring	supportive	social	environments.
• The	importance	of	community	participation	and	collaboration	between	all	
sectors	of	government	were	emphasised	as	crucial	aspects	of	healthy	
public	policy.
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Third	International	Health	Promotion	
Conference
• Held in Sundsvall,Sweden in 1991.
• Focused on linkingenvironmentalissues directlyto human health.
• Emphasised that Health Promotion has been, and should be concerned
with preservingand protectingnatural environments.
• An important link was thus made at this international conference between
those activities concerned with the promotion of health within
communities and those activities that focus on protecting the natural
environment.
6/1/18 Concept	of	HP	- Rakesh	Singh
United	Nations	Conference	on	Environment	
and	Development	(The	Earth	Summit)
• Held in Rio de Janeiro,Brazil in 1992.
• One of the outcomes of this conference was the development of a detailed
action plan outlining how member states could work towards sustainable
development.
• By sustainable development they meant development which meets the
needs of the present without compromising the ability of future
generations to meet their own needs.
• The action plan specifically highlights the role of local government in
achievingthis sustainability.
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Fourth	International	Health	Promotion	
Conference
• Held in Jakarta,Indonesia in 1997.
• First time it had been held in a developingcountry.
• Focused on identifying directions and strategies to address the challenges of
promotinghealth in the 21st Century.
• The main outcome of the conference was the Jakarta Declaration.
• In the Declaration, emphasis was placed on the importance of developing
new alliances and partnerships, for example between private and public, and
within government and non-government agencies.
• In addition,the declaration adopts a settings approach to Health Promotion.
• Settings refers to an approach to Health Promotion that focuses on a place
or a setting in which people gather, such as a school or a workplace, as
opposed to an illness or symptom.
• Health promoters were urged to build new alliances for health, including
private sector partnerships.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• In practice, this could mean that the local government structure, in
collaboration with the local community, identifies the major social,
economic and environmental issues that are going to pose substantial
risks to the environment and to publichealth.
• They then develop an integrated action plan to address the key issues,
both in the short and long term.
• Another approach might be for all stakeholders to identify key
environmental and public health goals that they would want incorporated
into the local government management plans, such as accessing
affordable housing, improving public transport, and ensuring community
safety.
6/1/18 Concept	of	HP	- Rakesh	Singh
Priorities	identified	by	JD
1. Promote social responsibilityfor health
2. Increase investments for health development
3. Consolidate and expand partnerships for health
4. Increase communitycapacityand empower the individual
5. Secure an infrastructure for health promotion
6/1/18 Concept	of	HP	- Rakesh	Singh
The	Fifth	Global	Conference	on	Health	
Promotion
• Took place in Mexico City from the 5-9th June 2000.
• It was entitled Bridging the Equity Gap.
• It had the followingobjectives:
q To show how Health Promotion makes a difference to health and quality
of life, particularlyfor those livingin adverse conditions.
q To place health high on the development agenda within international,
national and local agencies.
q To stimulate partnerships for health between different sectors and at all
levels of society.
6/1/18 Concept	of	HP	- Rakesh	Singh
Brainstorm
• In terms of the June 2000 HP conference,what is the significance of:
a) The switch to calling it a “global” rather than an “international”
conference?
b) The conference objectives and what they suggest about the future
direction ofHP?
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
a) The term “global” signifies that the conference is now bigger in scope,
involvingcountries from all over the world,rather than just some nations.
b) The conference objectives do not, however, introduce an entirely new
agenda for HP. Instead theystress new priorities:
• The role of HP in promoting development at all levels, particularly with
regard to poor countries.
• CollaborationaroundHP at all levels.
6/1/18 Concept	of	HP	- Rakesh	Singh
• The Bangkok Charter for HP (Thailand), 2005: New Context, Globalization
(advocate for health based on human rights, invest in sustainable
policies, actions and infrastructure, build capacity for policy development,
leadership, HP practice, knowledge transfer and research, and health
literacy; regulate and legislate to ensure a high level of protection,
partner and build alliance to create sustainable actions).
• Nairobi, 2009: Bridging the implementation gap (multiple participatory
processes, urgency to close the implementation gap in health and
development through HP, importance of HP as an integrative, cost-
effective strategy, and as an essential component of health systems
primed to respond adequatelyto emergingconcerns).
6/1/18 Concept	of	HP	- Rakesh	Singh
Further	Discourse	in	HP
Contd…
• Helsinki, Finland, 2013: Theme: Health in all policies (Inter-sectoral action
– action beyond health sector; its focus was on implementation, the “how-
to”).
• Shanghai, 2016: (health and wellbeing are essential to achieving
sustainable development, Good governance is crucial for health, Cities and
communities are critical settings for health, Health literacy empowers and
drives equity, accelerate the implementation of the SDGs through
increased political commitment and financialinvestment in HP)
6/1/18 Concept	of	HP	- Rakesh	Singh
ASSIGNMENT 2 – Assess the role of the private sector as outlined in the Jakarta
Declaration
Read the Jakarta Declaration on Health Promotion into the 21st Century:
a) What role you think the private sector or the sector which works for profit
could playin a Health Promotion project at a local or district level?
b) What do you think some of the difficulties might be in working with the
private or business sector at a local level?
6/1/18 Concept	of	HP	- Rakesh	Singh
Feedback
• If you are developing or managing a Health Promotion project at a local level,
it is likely that you would set up a steering committee or an inter-sectoral
team to co-ordinate the project.
• Like other role players in the district, a representative from the private sector
or business sector would be a member of this committee.
• Together the team would develop the vision for the project and start defining
project objectives and activities. A private sector representative might be
able to contribute to the project by:
q Providing resources such as a meeting space for the group and a venue for
workshops, covering the costs of printing materials or minutes of the
meetings.
q Providing skills and training in relation to project design and development,
such as strategicplanningprocesses or budgeting.
q Providing contacts and links with other businesses or private sector
institutions or networks.
q Supporting the implementation of the project on the ground e.g. by providing
the commitment and resources to implement the Health Promotion project
within their respective workplaces.
6/1/18 Concept	of	HP	- Rakesh	Singh
Contd…
• Some of the potential problems might be that private sector
representatives:
q Have less time to commit to the development ofthe project.
q Stipulate that there are specific requirements attached to the resources
they contribute to the project or the development process.
q Might have a different understandingofthe concept of Health Promotion.
q Might be pressurised to produce noticeable or tangible results from the
project early on in the process, thus reducing the level of community
involvement.
6/1/18 Concept	of	HP	- Rakesh	Singh
A	Framework	for	Health	Promotion	Activities
6/1/18 Concept	of	HP	- Rakesh	Singh
Preventive	Health	Services
• These include medical services, which aim to prevent ill-health through
immunization, family planning and personal health checks, as well as
wider preventive health services such as child protection services for
children at risk of child abuse.
6/1/18 Concept	of	HP	- Rakesh	Singh
Community-based	work
• This is a “bottom up” approach to Health Promotion, working with and for
people.
• It involves communities in health works such as local campaigns for better
facilities.
• It includes community development, which is essentially about
communities identifying their own health needs and taking action to
address them.
6/1/18 Concept	of	HP	- Rakesh	Singh
Organizational	development
• This is about developing and implementing policies within organisations to
promote the health of staffand customers.
• Examples include implementing policies on equal opportunities or
providinghealthyfood choices in staffdiningrooms.
6/1/18 Concept	of	HP	- Rakesh	Singh
Healthy	public	policies
• This involves statutory and voluntary agencies, professionals and the
publicworkingtogether to develop changes in the conditions ofliving.
• It is about seeing the implication for health in policies associated with
housing,employment,transport and leisure.
6/1/18 Concept	of	HP	- Rakesh	Singh
Environmental	health	measures
• This is about making the physical environment conducive to health,
whether at home, work or in publicplaces.
• It includes traditional public health measures such as providing clean food
and water, controlling pollution, as well as working on newer issues such
as providing smoke free areas in pubs or taverns and controlling the use of
environmentallydamagingchemicals.
6/1/18 Concept	of	HP	- Rakesh	Singh
Economic	and	regulatory	activities
• This includes political and educational activity directed at politicians,
policymakers and planners.
• It involves lobbying for and implementing legislative changes, such as food
labelling regulations and advocating for financial measures such as an
increase in tobacco legislation.
6/1/18 Concept	of	HP	- Rakesh	Singh
Health	education	programmes
• These are planned opportunities for people to learn about health and to
undertake voluntarychanges in their behaviour.
• Such programmes may include providing information, exploring values and
attitudes, making health decisions and acquiring skills to enable behaviour
change to take place.
• They involve developing self-esteem and self- empowerment so that
people are enabled to take action about their health.
• They can happen on a one-to-one level such as health worker to client
sessions, in a group, or by means of reaching large audiences through the
mass media and health exhibitions.
6/1/18 Concept	of	HP	- Rakesh	Singh
Concept of Health Promotion
Concept of Health Promotion
Concept of Health Promotion
Concept of Health Promotion

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Concept of Health Promotion

  • 2. Nowadays we hear a lot about Health Promotion (HP).... People refer to it in workshops and meetings.... Directors in DOHS use this term to describe nature of their work and development workers discuss HP in relation to health campaigns... But what is HP? What does it aim to do? What ideas underpin HP? 6/1/18 Concept of HP - Rakesh Singh
  • 3. TASK 1 - Identify common features of Health Promotion projects/programmes What examples of Health Promotion projects or campaigns do you know of, either at a national level or in your local district or region or state? What do all these projects/programmes have in common? 6/1/18 Concept of HP - Rakesh Singh
  • 4. National HP projects What they have in common Open Defecation Free Campaign § They raise awareness and promote skills to assist people/groups to change behaviour that is detrimental to their health. § They develop supportive environments in which healthier choices are easier choices. § They … improve health GBV: Zero Tolerance Red Ribbon HIV/AIDS Awareness Campaign Child Abuse Helpline Health promoting settings, e.g. Health Promoting Schools Health warnings on tobacco advertisements 6/1/18 Concept of HP - Rakesh Singh
  • 5. Feedback • .....HP programmes are often not flagged or labelled as such. • Instead, they are often found embedded within the broad activities of health and developmentorganisations. • They are also found in a variety of different settings, and assume different approaches. • HP activities are likely to be hidden within comprehensive integrated health activities of inter-sectoral action. 6/1/18 Concept of HP - Rakesh Singh
  • 6. Other common features of HP programmes • Provide information about health enhancing initiatives, health issues or a particular behaviour that has a negative effect on health e.g. no smoking campaigns. • Refer the public to other supportive structures or organisations that provide additional support to the particular issue e.g. a Childhelplinecounsellingservice. 6/1/18 Concept of HP - Rakesh Singh
  • 7. Contd… • Encourage the development of working partnerships across different sectors e.g. between health and transport, housing, engineering and planning. • Contain health promoting messages that are targeted at specific audiences and sometimes, developed in consultation with the target audience. • Contribute towards the development or implementation of healthy publicpolicy. 6/1/18 Concept of HP - Rakesh Singh
  • 9. • Looking at any complex society, one can identify three overlapping sectors of health care: 1. the popular sector i.e. the lay or non-professional sector; 2. the folk sector i.e. the traditional or sacred sector 3. the professional sector i.e. the legally-sanctioned sector such as western scientific medicine. • Each sector contributes to how one might experience and interpret what being healthy or sick means. 6/1/18 Concept of HP - Rakesh Singh
  • 10. • For example, under popular sector, one might start constructing one’s idea about health and illness from personal experience. q Experience of being sick, or taking care of family who is sickly. q Listening to neighbourhood or community beliefs or advice about how to keep away colds in winter or how important it is to eat certain foods to combat a particular illness. 6/1/18 Concept of HP - Rakesh Singh
  • 11. • Under folk sector, one construct ideas about health and illness from a traditional healer, a diviner or a spiritualist. q Health and illness is viewed by many in this sector as holistic with all aspects of life being equally important. q In other words, one’s relationship with others, the natural environment, supernatural forces and any physical and/or emotional symptoms would all be considered in a consultationwith such a healer. 6/1/18 Concept of HP - Rakesh Singh
  • 12. • Professional sector - western scientific medicine or allopathy, includes medical practitioners. This sector holds a dominant positionin our society. • People’s ideas about health and illness will not be constructed from any sector alone – nor will they necessarily seek relief from illness from a single health practitioner or healer. • A health worker need to move between the popular, the folk and the professional sector. 6/1/18 Concept of HP - Rakesh Singh
  • 14. DIFFERENT CONCEPTS OF HEALTH • Difficult to define as everyone has a different concept of health • But it can be conceptualised or understoodmentally • In other words, you can describe your concept of health but not necessarily define it. • The important thing is to think about your concept of health and to be able to articulate and communicate it to others. 6/1/18 Concept of HP - Rakesh Singh
  • 15. Contd… • Equallyneed to respect other’s concepts of health. • If to my neighbour or my colleague, being healthy means being fit and never being ill, whereas to me health means to have a sense of wholeness, well-being and peace – one should acknowledge and respect this difference in opinion. 6/1/18 Concept of HP - Rakesh Singh
  • 16. Contd.. • Many researchers and writers have explored different definitionsor concepts of health. • Discussed in terms of lay and health professional concepts or definitionsof health. • For example, a British Sociologist, Mildred Lillington Blaxter (1990) working from a British sample of 9000 people, grouped their lay definitions of health into a number of different perspectives. It included: 6/1/18 Concept of HP - Rakesh Singh
  • 17. Contd… • Health as not ill or diseased i.e. the absence of disease. • As individual behaviour e.g. if someone lives in a healthy way, does exercise and or does not drink or smoke. • Physical fitness e.g. being fit or strong, or lookinghealthy. • Energy e.g. having energy and enthusiasm to do things. • Social relationships e.g. health in terms of relationships with other people. • Function e.g. being able to carry out normal routines or having the ability to do things. • Psycho-social well being e.g. being in a state of good mental health. 6/1/18 Concept of HP - Rakesh Singh
  • 18. Contd.. • Consider how important it would be if you were developing a national HP campaign (for example with the 9 000 individuals that Blaxter included in her sample), to bear in mind just how diverse people’sideas about health are. • Also important to bear in mind the influence that the popular, folk and professional sectors have on influencing your audience’s interpretationof health. 6/1/18 Concept of HP - Rakesh Singh
  • 19. • Discussing professional as opposed to lay perceptions of health, it is notable that perceptions are influenced by particular model of health or illness to which they subscribe. • In HP literature there are often references to two opposing views of health: the bio-medical model and social model of health. 6/1/18 Concept of HP - Rakesh Singh
  • 20. Medical and Social Models – two views of health • Bio-medical- “the absence of disease” ....Assumption-disease is generated by specific agents- changes in the body... Emphasises the importance of alleviating symptoms or curing diseases. • Define health “… more by what it is not than what it is”. • This model halts its analysis at the actual disease – exploring other determinants (apart from specific agent). • Limited emphasis on preventionof disease. 6/1/18 Concept of HP - Rakesh Singh
  • 21. Social Model • Views health and ill health as being caused not by diseases alone but by social conditions(poverty, gender, violence.....) • Emphasises positive side of health...Defines-in terms of a state of well-being. • The link between the physical, psychological and social processes also suggests that health is more holistic in nature, as is illustrated by WHO Definition. 6/1/18 Concept of HP - Rakesh Singh
  • 22. • Health Promotion: A Discussion Document on the Concept and Principles, WHO – health as a human right and something which requires prioritisation and social investment by all, including governments, organisations, business and others. • “The extent to which an individual or group is able,...to realise aspirations (desire) and satisfy needs, and...to change or cope with the environment. Health, therefore, is seen as a resource for everyday life, not an object of living; it is a positive concept emphasising social and personal resources, as well as physical capacities” (WHO, 1984). 6/1/18 Concept of HP - Rakesh Singh
  • 23. TASK 2 - Classify different perceptions of health Responses to “What is needed in order to feel healthy and live a healthy life?. Classifythese responses accordingto the two different models ofhealth. Having money No natural disasters (e.g. floods) Having interesting, challenging work Having a flushing toilet Good roads Feeling secure from danger or threat Not to have diseases I can’t easily cope with Not to have TB Not smoking Protected from discrimination Having good friends Having a job Having a house No violence Feeling happy Having enough food Feeling well, happy, stimulated by life and spiritually content A clean environment Feeling spiritually fulfilled Being fit and lean To feel strong and keen to take on new challenges 6/1/18 Concept of HP - Rakesh Singh
  • 24. a. Different ways of classifying these responses. b. Being healthymeans different things to different people.Influenced by: q The context in which they are living e.g. geographical or physical location, housing,income,employment status. q Current health status. q Knowledge,experiences and beliefs about health. As a health promoter, it is always important to reflect on what being healthy means to you and what it means to your clients, .... important influence on the approach to HP. c. As a health promoter there will invariably be things that you cannot directly help your clients with. For example, ensuring that there is an accessible, well maintained and safe public transport system falls outside of health service’s responsibility. However, a health worker.....start lobbying...to put more traffic officers on duty around schools and parks, or to run educational campaigns about road safety at primary schools.....HW begin to work inter-sectorally to reduce the high rate of traffic accidents or to increase road access to rural villages. Professional skills or experience Broader developmental issues 6/1/18 Concept of HP - Rakesh Singh
  • 25. BIO-MEDICAL MODEL OF HEALTH INDIVIDUAL COMMUNITY §Not to have diseases I can’t easily cope with §Not to have TB §To quit smoking §To be fit and lean §To feel strong and keen to take on new challenges §Having money §Having a job §To be happy §Protection from discrimination §Having good friends §No violence §Good roads §A clean environment §Having a house §Feeling secure from danger §Having a flushing toilet §Having enough food §No natural disaster (e.g. floods) §Having interesting work §Feeling spiritually fulfilled §To feel well, happy and stimulated in my life, and to be spiritually content SOCIAL MODEL OF HEALTH6/1/18 Concept of HP - Rakesh Singh
  • 26. Dimensions of health • When people speak about being healthy, they refer to a number of different areas of their daily lives. • These different areas have been conceptualised as different dimensions of health. 6/1/18 Concept of HP - Rakesh Singh
  • 27. PHYSICAL MENTAL EMOTIONAL SOCIAL SPIRITUAL SEXUAL ENVIRONMENTAL SOCIETAL Dimensions of Health 6/1/18 Concept of HP - Rakesh Singh Individual D Broader/Societal D Health interrelated to all aspects “Holistic Concept of H”
  • 28. TASK 3 – Define (Health) Promotion a) What does promote or promotion mean to you? b) Given your concept of health, what does Health Promotion mean to you? c) In order to promote health what information do we first need to understand? 6/1/18 Concept of HP - Rakesh Singh
  • 29. Feedback a) To promote means to advance, assist, encourage, lend support to, market, publicise, help the progress of something, push for. b) Health Promotion means to advance, to assist or to push for a better healthier life for people. To use an analogy: health and development workers often feel like they spend all their time standing on the banks of fast flowing river lifting people to safety. The health promoter works upstream and tries to find out why people are falling into the river from the beginning and how one can work together in preventing such things from happening in the future. c) In order to promote health effectively with individuals and communities, first need to understand the causes or determinants of ill-health. 6/1/18 Concept of HP - Rakesh Singh
  • 30. Determinants of Health • Two other factors which affect our way of seeing or conceptualisingHP: 1. Determinants or causes of health and ill health 2. Inequity and explore how these factors impact on definition and understandingof HP. 6/1/18 Concept of HP - Rakesh Singh
  • 31. • Like your definition of health, what you view as the determinants or causes of health also influences your interpretationof HP. • They affect the way you view the purpose of HP and the kinds of interventionsthat you choose to make. 6/1/18 Concept of HP - Rakesh Singh
  • 32. TASK 4 - Identify some of the determinants of health and ill- health Jot down categories of determinants or causes of health or ill- health and rank them according to which ones you think are the most important or have the most influence. 6/1/18 Concept of HP - Rakesh Singh
  • 33. 1. Genetic factors - determine individual’s predispositionto disease. 2. Biological factors - diseasecaused by bacteria or viruses. 3. Individual behavioural factors - contribute to disease, such as smoking, drinking, lack of exercise. 4. Socio-culturalfactors,such as traditional,religious beliefs and practices. 5. Factors around work and living conditions, such as housing, sanitation, transport, access to health services, income, adequate nutrition and employmentopportunities. 6. Environmentalfactors,such as pollution, level of violence. 7. Broader political, economic and social factors, such as a country’s constitution and laws, prevailing economic system, the available resources and how these are distributed. These factors affect the way in which a society is structured or stratified, e.g. in terms of class, gender, race, age. They also impact upon the other factors. DETERMINANTS 6/1/18 Concept of HP - Rakesh Singh
  • 34. Ranking of Determinants • Influenced by your view of health and in turn influence where you, as a health promoter,place your efforts. • Depend on your judgement of the issues, but also the perspectives of those you work with and the feasibilityofanyintervention. • For example, if you were working with a group of youth and believed that individual behavioural factors as the most important determinant to tackle, you might focus on individual skills building session. These could include discussion sessions on how youth could stop smoking or taking drugs or how they should practise safer sex or encourage youth to take up some form of sport. • However, if environmental factors such as the high levels of violence or factors associated with poor living conditions were seen as priorities, you might focus on advocating for the development of community safety programmes, or for changes to be made in the design and layout of low-cost housing schemes, and you might work with the local communities to become involved in lobbying for stricter legislation regardinggender-based violence. 6/1/18 Concept of HP - Rakesh Singh
  • 35. How the categories interact • Political, economic and social factors - affects the other categories in various ways. • For instance, consider how the following government laws and policies could determine and change economic and social conditions and how those changes would impact on other levels of health: q Providinghousingsubsidies for the poor. q Expandinglocal health facilities to rural areas. q Ensuring equal work opportunities for men, women and the physically challenged. q Restrictingthe levels of industrialpollution. q Assertingthe propertyand inheritance rights of women . q Supportingthe right of women to terminationofpregnancy. q Banningsmokingin publicplaces and prosecutingdrunken drivers. 6/1/18 Concept of HP - Rakesh Singh
  • 36. Contd… • This intervention could improve the environment as well as the working and living conditions. It could also challenge unhealthy cultural and social practices, and reduce the negative effects of these factors, particularly on the health status of disadvantaged or vulnerable groups. • These broad determinants all have a major impact on the health of the population. 6/1/18 Concept of HP - Rakesh Singh
  • 37. TASK 4 – Classifying the determinants of HIV/AIDS In the first column of the diagram below, jot down all the determinants that you can think of in relation to women’s experience of HIV/AIDS. Classify each of your determinants by ticking the category of determinants, into which it fits (provided two examples of determinants to guide you). Think of ways in which any of these categories of determinants are linked? Categories of determinants Determinants Genetic & biological Individual beliefs Socio- cultural Work & living conditions Environ- mental Political, economic,s ocial Anatomically, women are more at risk of HIV infection than men. √ Some religions forbid the use of condoms, thereby increasing the risk of HIV transmission. √ Include further determinants here. ê Classifying the Determinants of HIV 6/1/18 Concept of HP - Rakesh Singh
  • 38. • What we are trying to illustrate here is the complexity of the situation and the fact that many different factors contributeto this/any health problem. • Addressing it as health promoters therefore requires you to be aware of the complexity of the determinants and their inter-connectedness. 6/1/18 Concept of HP - Rakesh Singh
  • 39. Determinants Discussion of the interconnections between determinants Genetic & biological factors HIV, a virus, passes from one person to another through vaginal fluids and semen, during sexual intercourse, through blood, during childbirth, infected blood, through a needle stick injury or through IDUs. Anatomically women at more risk, as larger exposed surface area of the vagina and labia. In addition, mucosal surfaces in vagina are more susceptible to be affected compared to hardened penile skin. It is well documented that co-existing STDs increase the risk of HIV transmission – 9 times greater where one partner is HIV+. Women are particularly vulnerable in relation to this risk, as their symptoms are often non-specific or asymptomatic or might not be perceived to be serious enough to seek treatment. STDs in women thus often go undetected, thereby increasing women’s risk of HIV and giving rise to infections. INTER-CONNECTEDNESS OF, DETERMINANTS OF HIV/AIDS EPIDEMIC IN RELATION TO WOMEN’S EXPERIENCE 6/1/18 Concept of HP - Rakesh Singh
  • 40. Determina nts Discussion of the interconnections between determinants Individual behavioural factors Men and women who have many sexual partners and do not use condoms, IDUs who share needles and syringes and HW who do not practise universal precautions are placing themselves and others at risk of HIV transmission. The use of alcohol and drugs... rational decisions about safer sex practices... in relation to the HIV epidemic. For example, ... Decisions regarding using a condom, having safer sex or in fact deciding not to have sex. Alcohol level of violence, including sexual violence, which would then place women in a position of risk. 6/1/18 Concept of HP - Rakesh Singh
  • 42. Determinants Discussion of the interconnections between determinants (continued) Factors around work and living conditions In some communities, women do not have equal access to on-going training and tend to be excluded from the formal economy. Where women have been able to access skills and training, they have not always had the power to negotiate equivalent work positions or conditions as their male colleagues. Having had less choice around what work they are able to do, women have often had to explore other work options, such as sex work, or in some cases, accepting gifts, favours or a place to stay, in return for sex. In these situations, where women are economically dependant on their clients/men, they are likely to be placed in a situation where they accept money for sex without using a condom, or have to suffer abusive sexual situations. The level of sexual violence is increasing thereby increases their vulnerability to HIV infection. Environmental factors General degradation of environment, for example, lack of street lighting creates an environment which is not safe for women to walk in. 6/1/18 Concept of HP - Rakesh Singh
  • 43. Determinan ts Discussion of the interconnections between determinants (continued) Gender In general, women have less power, not in a position to talk about and negotiate safer sex practices. A woman is also more at risk of violence, abuse or rejection by her partner if she asks him to use a condom . Women have less power to negotiate equal salaries and employment opportunities....more economically dependent on men. This has had grave consequences for women when they have informed their partner that they are HIV+, as often the partners have literally chased the women out of their homes. Women have in many cases had to leave all their possessions and find accommodation elsewhere, which in turn has increased their vulnerability to further discrimination. Lack of appropriate information places women in a less informed position, where they are unable to anticipate or identify risky HIV practices. Information about human rights and the rights of women has also not been conveyed to young people.......domestic violence and customary marriage law of. 6/1/18 Concept of HP - Rakesh Singh
  • 44. Determinan ts Discussion of the interconnections between determinants (continued) Broader political, economic, and social factors Migrant labour system....men often had multiple sexual partners, which placed their primary partner at risk of HIV infection when he returned home. Women were left to work at home....suffer considerable hardship and poverty. In case of husbands falling ill or dying, women are left in an even more vulnerable position. ...to have sex in exchange for food, shelter and support for their children. People are not aware of laws which protect people in the workplace and support anti-discriminatory HIV/AIDS. A lack of knowledge about these laws is disadvantageous to women, particularly in the workplace. For instance, a woman living with HIV/AIDS might face discrimination in relation to how her colleagues treat her....affect opportunities for promotion or to receiving benefits that she would normally receive ..... potentially at risk of experiencing different levels of discrimination in terms of their access to treatment, care and support. 6/1/18 Concept of HP - Rakesh Singh
  • 46. • Broader political, economic and social factors are linked to other determinants and have an influence,either negativelyor positively. • For example: q Migrant labour system. q The laws did not support the principle of equity or protect against discrimination. q Affected the working and livingconditions ofwomen. • Women were (and still are) not afforded the same status as men and not given equal access to formal employment and ongoing training opportunities. Their earning power is thus reduced, and until recently, they have not had adequate legal protection against gender discrimination in the workplace,or gender violence at home or in the broader community. 6/1/18 Concept of HP - Rakesh Singh
  • 47. • Further example illustrate the link between socio-cultural, gender factors and biological factors. In a situation where a woman is placed at risk of HIV transmission for instance, when she is having sex with her partner, she might not have the confidence, the skills, the economic self-sufficiency or even the choice to insist that she is protected from the risk of HIV transmission. Coupled with her biological susceptibility, a woman is thus placed in a significantly more vulnerable position. • Another example is the situation of HIV+ woman who has to make complex decisions about motherhood. For instance, if she decides to have a child, she risks transmitting HIV to her child and then has to live with the consequences of this decision if her child is HIV+. If she decides not to have a child, she might face rejection and even potential abuse from her partner and her family. Mother-to-child transmission also inadvertently carries with it a stigma, as women are seen as the carriers of the disease. This reinforces a commonly held belief that women are in fact to blame for the epidemic. 6/1/18 Concept of HP - Rakesh Singh
  • 48. • Ultimately all these determinants have a role to play in determining the level or health status ofthe individualor community. • Because of the relationship between all these factors, people working in the area of Health Promotion need to consider all of the determinants when developing and implementing an intervention in relation to women and HIV/AIDS (any health problem), whether targeted at the general public,at men, at the youth or at women. 6/1/18 Concept of HP - Rakesh Singh
  • 49. LEVELS OF DETERMINANTS • National or global levels: Related to broader economic, political and social causes, such as the system, laws and regulations. • Environmental levels: Related to the living and working environments, and the natural environment. • Community levels: Related to community practices, attitudes and norms. • Individual levels: That are close to or part of an individual, like those relating to genetic, biological and physical causes and individual behaviour. 6/1/18 Concept of HP - Rakesh Singh
  • 51. • In HP, recognising how determinants are inter-linked, try to tap into and work with the different levels. • For example, with HIV, try to encourage young women to delay practising sex, or to ensure that they seek immediate treatment for STDs. This is an intervention that taps into the most individual or local level of determinants. • However, working with only one level of determinants could be detrimental to our health development workin the longterm. • For example, whilst we may be ensuring that women receive early treatment for their STDs, we have not adequately dealt with the fact that women also need to be provided with the skills to prevent STD infection. For instance, they need easy access to condoms and to be able to communicate effectivelywith their partners. 6/1/18 Concept of HP - Rakesh Singh
  • 52. • As health promoters, different levels of determinants need to be looked upon so that development of realistic health promotion interventions can be done. Take for example the issue of the large numbers of children with scalds and burns. • As a health promoter working in such an institution, one would begin to think about what role the team could play or what would be an appropriate intervention to assist in reducing such accidents. 6/1/18 Concept of HP - Rakesh Singh
  • 53. Perhaps asking the question “Why?” could begin such a brainstorm session: • Why are we seeing so many children with burns and scalds? • Is it because families are living in crowded, informal houses without adequate cooking and cleaning facilities? • Is it because adults are unaware of the care and precautions that need to be taken when using paraffin, gas or hot water near children? • Is it because children are being left at home unsupervised – without adequate adult supervision? • Is it because the accident prevention campaigns have been inadequate? • Is it because parents have no choice but to leave their children at home as they need to go out and work and are unable to afford regular childcare? 6/1/18 Concept of HP - Rakesh Singh
  • 54. • By asking the question “why?”, focus on the cause upstream and then begin to consider how one might plan an intervention that focuses on both those determinants that are close to the individual (like educating parents and care-givers about safety in the home) and broader determinants like housing regulations,access to electricity and water and economicopportunities. • In planning an intervention, the HP team might consider setting up a joint project with the concerned stakeholders to host an awareness raising workshop. • Also consider advocating small business initiative to establish child care so that working parents can leave their children in safety. • The team might also consider working with local businesses that are selling gas, paraffin and cooking utensils to support a child safety campaign. For example, they could ask shop owners to display posters about safety and to stock and sell paraffin safety caps - a campaign which could be supported by a local community-based radiostation. 6/1/18 Concept of HP - Rakesh Singh
  • 55. Health Promotion intervention Level of determinant Advocate that workplaces offer adequate opportunities for workers to be supported in taking their TB treatment. Establish a community-based condom distribution and education programme. Encourage TB patients to join a directly observed treatment shortcourse (DOTS) programme. Encourage family and household members ofTB patients to come to the clinics for screening. Advocate for the introduction oflegislation which ensures thatpeople living with HIV/AIDS are not discriminated againstin the workplace or within the health services. Encourage young adolescentwomen to delay practising sex. Produce preventive HIV educational materials and facilitate lifeskills sessions for youth. Educate children abouthow to clean their teeth regularly and correctly. Implementan inter-sectoral programme thatencourages other developmentprojects and organisations to work in collaboration with the health services in informing their clients abouthow to preventTB, the signs and symptoms of TB and how to access treatment. Advocate for an optimal level of fluoride to be maintained in the local water supply. Ensure that men and women seek immediate treatment for STDs. Advocate for improved quality in housing construction,so as to reduce overcrowding and improve ventilation. Run educational workshops on gender and violence for local councillors. Encourage parents to adopthealthy eating routines for their children e.g.less sugar and less frequently. TASK 6 – Identify levels of HP interventions Listed below are some HP interventions that have commonly been used in relation to the three health issues HIV/AIDS, TB and tooth decay. Identify which level of determinants each intervention tries to address. 6/1/18 Concept of HP - Rakesh Singh
  • 56. Determinants close to the individual • Encourage youngadolescent women to delaypractisingsex. • Ensure that men and women seek immediate treatment for STDs. • Encourage TB patients to join a directly observed treatment shortcourse (DOTS) programme. • Encourage family and household members of TB patients to come to the clinics for screening. • Educate children about howto clean their teeth regularlyand correctly. • Encourage parents to adopt healthy eating routines for their children i.e. less sugar and less frequently. • Produce preventive HIV educational materials and facilitate lifeskills sessions for youth. • Establish a community-based condom distribution and education programme. 6/1/18 Concept of HP - Rakesh Singh
  • 57. Determinants that relate to living and working conditions and the natural environment • Implement an inter-sectoral programme that encourages other development projects and organisations to work in collaboration with the health services in informing their clients about how to prevent TB, the signs and symptoms ofTB and howto access treatment. • Advocate that workplaces offer adequate opportunities for workers to be supported in takingtheir TB treatment. 6/1/18 Concept of HP - Rakesh Singh
  • 58. Determinants that relate to broader economic, political and social causes, such as systems, laws and regulations • Advocate for the introduction of legislation which ensures that people living with HIV/AIDS are not discriminated against in the workplace or within the health services. • Advocate for an optimal level of fluoride to be maintained in the local water supply. • Advocate for improved quality in housing construction, so as to reduce overcrowdingand improve ventilation. 6/1/18 Concept of HP - Rakesh Singh
  • 59. • A single HP intervention, whilst it might be aimed at a particular set of causes or level of determinants, might also have an impact on the other levels of determinants. • For example, running an educational workshop on gender and violence for local councillors (activist/leaders) in a community is a HP intervention aimed at increasing awareness about the issue....thus aimed at determinants close to individual. However, it might also encourage the participants to reflect on how safe their communityis for women. 6/1/18 Concept of HP - Rakesh Singh
  • 60. • They might then lobby for changes in their environment and in local government regulations, which try to reduce the current level of gender violence.Such intervention might include: q Advocatinglife-skills programmesbe run in all schools. q Installingmore street lights in each neighbourhood. q Training the local health workers and police force on gender issues and gender violence. q Increasing the allocation of resources to the police service in order that more communitypolice officers can be employed at local police stations. q Introducing new regulations on the handling of domestic violence by the police. 6/1/18 Concept of HP - Rakesh Singh Individual L & W EnvBroader
  • 61. • Dividing determinants into categories is a useful analytical tool that helps to recognise the importance of addressing the different levels of causes of ill health. • It is important in the process of planninga HP intervention to consider: q firstly, how the different levels of determinants interact with one another in causingill health or a disease,and q secondly, how HP interventions aimed at different levels of determinants could work alongside and complement one another. • Generally, an intervention aimed at only one level of determinant will have less chance of success than a Health Promotion intervention that recognises the different levels of determinants. 6/1/18 Concept of HP - Rakesh Singh
  • 62. INEQUITY AND HEALTH PROMOTION • Talking about health determinants,inevitablyraises the issue ofinequity. • Individuals, communities and countries with the least resources unfairly carry the burden of ill-health and mortality. • The link between poverty and ill health is apparent where differences exist between the different sectors of our society. • The distribution of inequity generally reflects or falls along the lines of race, class, gender and age. 6/1/18 Concept of HP - Rakesh Singh
  • 63. • When working in the field of HP, it is important to clarify what you and others understand health to mean, and what the causes or determinants of ill-health are. • It affects the way you and others view the purpose of HP, the ideals and values upon which HP activities are based and the choices made in developingHP interventions. • People’s definitions ofHP embodythese ideas. 6/1/18 Concept of HP - Rakesh Singh
  • 64. TASK 7 - Summarise the factors which affect your understanding of HP Take some minutes to make a mindmap of your understanding thus far of the factors which affect your understandingofHealth Promotion e.g. inequity. So far we have looked at definitions, perceptions and determinants of health, including the issue of inequity. These ideas helped us to clarify what we mean by health. They are also crucial to understanding what we mean by Health Promotion. 6/1/18 Concept of HP - Rakesh Singh
  • 65. TASK 8 - Analyse definitions of Health Promotion Read the six definitions of HP below. What concept and model of health and what determinants of health is each one likely to be based on? 1. “Health Promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, Health Promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being” (Ottawa Charter for Health Promotion, 1986). 2. “Health promotion is health education and related organisational, political and economic interventions that are designed to facilitate behavioural and environmental changes to improve health” (Green in Wass, A. 1994: 39). 3. “The terms health promotion and health education are not interchangeable. Health promotion covers all aspects of those activities that seek to improve the health status of individuals and communities. It therefore includes both health education and all attempts to produce environmental and legislative change conducive to good health. Put another way, health promotion is concerned with making healthier choices easier choices” (Dennis et al, in Naidoo & Wills, 1994: 77). 4. “Health Promotion work has to recognise the prevailing social, economic, political and cultural context in which we all live. In recognising the powerful links between personal and political issues, we assert the need to challenge inequalities and oppression wherever they may arise. Health promotion work seeks to oppose inequity and oppression based on race, ethnicity, age, gender, disability, class, sexual orientation and religious belief. The task of health promotion is to enable, facilitate and empower individuals, groups and communities in order that they gain and maintain control of their lives and their health. Education and training for health promoters must be compatible with these aims” (Dr Rachael Dixey, Leeds Metropolitan University, UK). 5. “Health promotion is the art and science of helping people change their lifestyle to move towards a state of optimal health” (O’Donnell ,M. in Reddy & Tobias, 1994: 23). 6. “Health promotion is a set of activities that aim to promote healthy living and to prevent disease through information, skills building and the provision of health care” (South African health and development worker). 6/1/18 Concept of HP - Rakesh Singh
  • 66. • Definitions (1) to (4) emphasise the Social Model of health. They support the idea that health is a positive, holistic concept and that the health of individuals and communities is affected by a range of determinants (social, political, economicand cultural). • Whilst it is generally accepted that the Ottawa Charter is strongly based within a Social Model of Health framework, some people have interpreted the first line of the Charter as being conservative. In other words they believe that whilst one might be able to increase the level of control one has over one’s health, that does not necessarily mean that one is assured of being able to live in a good social environment. • Definitions (5) and (6) are somewhat narrower and seem to imply a focus on promoting the health of individuals. They emphasise biological and individual behavioural determinants. 6/1/18 Concept of HP - Rakesh Singh
  • 67. Some of the common themes which underpin the first three definitions are: • HP is a process - it does not happen overnight, but is rather a longer-term set of sustained activities and interventions. • HP aims to improve the health status of individuals and communities and enable them to gain increased control over their health. • Based on the philosophyofself-empowerment. • Entails different strategies, such as providing information and building skills, to developingpolicyand legislation. • HP is not equivalentto health education,but encompasses it. • Involves inter-sectoral action and workingin partnershipwith other sectors. 6/1/18 Concept of HP - Rakesh Singh
  • 68. • The last two definitions of HP are considerably more individualistic in their emphasis and would most likely be focused on working towards attitude and behaviour change within a health care setting. • They assume that individuals have considerable influence over their environment, and that a healthy outcome would automatically result from the changes made in behaviour. 6/1/18 Concept of HP - Rakesh Singh
  • 69. • One of the challenges that a health promoter may be faced with is working in an environment where different parties hold different understandings ofHP. • Our conceptualisations affect our responses to health problems and strategies for HP; health promoters need to develop a way of dealing with these differences. The next task offers you an opportunity to prepare yourself for this problem. 6/1/18 Concept of HP - Rakesh Singh
  • 70. TASK 9 – Managing different understandings of Health Promotion Imagine that you are going to set up a HP project involving health colleagues, other professionals (such as teachers and engineers) and community members. It is likely that everyone does not share the same understanding of health and of the role that determinants play in influencing health or ill health. People are also likely to have had different experiences, and thus have different levels of familiaritywith the concept of HP. a) How would this affect the project? b) How would you cope with this situation? c) What would you do at the start of the project? 6/1/18 Concept of HP - Rakesh Singh
  • 71. Feedback • Universally, it is unlikely that a single concept of health, which is acceptable to all, will ever be developed. • Instead,diverse and competingdefinitions are inevitable. • This can lead to confusion, misunderstanding and lack of true co-operation when settingup a HP project. • Ultimatelythis can undermine the success of the project. • To address these problems and to work successfully with colleagues and the community, it is important for everyone involved to share their understandingofhealth and HP. 6/1/18 Concept of HP - Rakesh Singh
  • 72. Contd.. • You could suggest that this be done as part of an ice-breaker or introductory exercise in your first meeting or workshop. • You could then reach consensus on the main elements of these definitions through group discussion. • This awareness-raising exercise could be the first step towards establishing a good working relationship and forging a closer understanding of what HP means for your team members. • It might also allow the group to start thinking about the appropriate level of determinants to target the HP intervention. 6/1/18 Concept of HP - Rakesh Singh
  • 73. AIM GOAL Health Promotion A process of enabling people to increase control over the determinants of Health and thereby improve health It embraces actions •Directed at strengthening the skills & capacities of individuals so that they can change and cope with the environment. •Directed towards changing social, environmental & economic conditions to alleviate their negative impact on public or collective health and individual health. PRINCIPLES & METHODS •Participation is essential to sustain health promotion •Health Promotion action is not the responsibility of the health sector alone-it involves all sectors, systems and structures that govern our social, economic and physical environment. 6/1/18 Concept of HP - Rakesh Singh
  • 74. TASK 10 – Reflect on your initial definitionof Health Promotion Look back at your definition of health promotion in Task 2. Are you still comfortable with this definition? If you are, that’s fine! However, if you feel that you have a different understanding of Health Promotion now, try rewriting your original definition to fit with your new thinking. 6/1/18 Concept of HP - Rakesh Singh
  • 75. • By now, you probably have a fairly strong sense of how our values, experiences and our own critical perspectives influence the way we conceptualise Health Promotion,and therefore the strategies we use. • In order to develop our understanding even further, we need to look at the history of the Health Promotion Movement to find out where Health Promotion originated. 6/1/18 Concept of HP - Rakesh Singh
  • 77. AN OVERVIEW OF THE HISTORY OF HEALTH PROMOTION TASK 11 – Clarify some terms Historical accounts often describe particular events, gatherings of people, documents, laws etc as landmarks, milestones and watersheds. What do each of these three terms mean, in their original usage or literally and in everyday usage? 6/1/18 Concept of HP - Rakesh Singh
  • 78. • A landmark literally means an object that is easily seen in a landscape. In everydayuse it means an important historicalevent. • A milestone literally referred to a stone that used to be placed beside the road to mark the distance between towns. In everyday use it also means an importantevent in life or history. • A watershed literally describes a line of high land from which streams flow down on all sides. In everyday use it means a turning point in the course of events. 6/1/18 Concept of HP - Rakesh Singh
  • 79. TASK 12 – Think about the history and forerunners of Health Promotion a)What do you know about the history of Health Promotion? Where, when, how and why did it start? What were the landmark or watershed dates, events and documents associated with it? Jot down any knowledge you have in a mind map like the one below. b)The origins of the term Health Promotion is linked to activities that took place around the 19th centuryin Europe.Whyis this? c)Can you think of any examples of health promoting activities which took place earlier in history,and in places other than Europe? History of Health Promotion 6/1/18 Concept of HP - Rakesh Singh
  • 80. a) Your mind map will be helpful in reminding you that you already have some prior knowledge about the topic b) 1. The term Health Promotion is associated with 19th century Europe because this was the first time in more recent history when public health concerns were officiallyrecognised and seen to be of national importance. 2. It is interesting to note that many of the popular Health Promotion texts start discussing the history of Health Promotion from this period (i.e. the 19th century) onwards and focus exclusively on public health legislation and reform that was implemented in Europe,Britain or North America. 6/1/18 Concept of HP - Rakesh Singh
  • 81. Contd… 3. Very few writers begin discussing the history of Health Promotion by using examples of Health Promotion interventions from earlier centuries or describing traditional indigenous practices or beliefs about health and disease. 4. It is an interesting bias and reflects the focus of the authors on documenting events in their own countries for the interest of their first world readers. 5. It is also perhaps a reflection on the lack of documentation about indigenous health practices which were considered by many in the colonial era to be unscientific. 6. This was partly because practices were transferred from one generation to the next through oral tradition and oral communication rather than the written word. 6/1/18 Concept of HP - Rakesh Singh
  • 82. Contd… c) However, histories of Public Health show that some form of collective public health measures have always been implemented by societies. Strategies to promote health would have inevitably formed a part of these measures, although these would not have been called HP. Examples include: -The Roman publicbaths. -Roman laws governing burial of the dead and regulating dangerous animals and unsound goods. -The regulation ofprostitution in Ancient Rome and Greece. -Inoculation against smallpoxin India and China before the Christianera. -The isolation of people with leprosy in Europe in the Middle Ages (5-15th Century. -The quarantiningofships by the Venetians (Italy). 6/1/18 Concept of HP - Rakesh Singh
  • 83. • Western concept of public health and concepts of health and disease would have had little relevance or significance to the indigenous people as hunter gatherers they did not have the Public Health problems associated with permanent settlements. • Traditional healers use of natural products for healing was part of the indigenous practice which had little connection to European concepts of Public Health. • The world including developing nations have a rich history of indigenous healing. To what extent has this indigenous practice been incorporated into the recordingof our local Health Promotion history? 6/1/18 Concept of HP - Rakesh Singh
  • 85. The Health Promotion Movement The four key movements or eras affecting HP: 1. Early Public Health Movement i.e. the concern with environmental conditions. 2. Medical Era i.e. the belief that medicine had all the answers. 3. Health Education Era i.e. that medicine does not have all the answers. 4. New Public Health Movement/Health Promotion Era i.e. that Health Education does not solve everything and can result in blaming the victim. 6/1/18 Concept of HP - Rakesh Singh
  • 86. DIFFERENTIATING HEALTH EDUCATION AND HEALTH PROMOTION • Since the mid-1980’s, there has been considerable debate about the difference between Health Promotion and Health Education. 6/1/18 Concept of HP - Rakesh Singh
  • 87. TASK 12 – List the differences between Health Education and Health Promotion Jot down the main differences between Health Education and Health Promotion in terms of their •Aims. •Activities and strategies. 6/1/18 Concept of HP - Rakesh Singh
  • 88. • Both have the same aim, “to improve or protect health”. However, the scope of their activity varies. • In the case of HE, most activity centres on providing learning opportunities for individuals and communities so that they are able to voluntarily change their behaviour. • They acquire information and skills to help them initiate a change that enhances their well-beingand their health. • HP activity is much broader and includes both HE And: 1. The provisionofpreventative healthservices. 2. Measures to protect the physical environment and make it conducive to health 3. The mobilisationofcommunityresources. 4. The implementationoforganisational policies which promote health. 5. Economicand regulatoryactivities. 6/1/18 Concept of HP - Rakesh Singh
  • 89. HP Vs HE • The two concepts,HE and HP are symbioticstrategies. • A key feature that distinguishes HP from HP is that HP involves environmental and political action. • Similarly, Tones and Tilford (2001) have suggested that it is possible to distil the concept of HP into an essential formula: Health Promotion = Health Education x HealthyPublicPolicy • HP is the product of both HE and HPP. • The multiplication sign x literally means to add a given amount several times over. • Here the given amount is HE which is added as manytimes over as HPP. • In other words, when HE and HPP are multiplied, they produce a far greater effect than just the sum of the two. HE and HPP - if implemented together produce an effect that is far greater than the individual parts. • This formula serves to illustrate how central both Health Education and policy are to the achievement of individual, community and national health status, and how symbiotic or inter-connected the relationship is between Health Education and the broader activityofHealth Promotion. 6/1/18 Concept of HP - Rakesh Singh
  • 90. Contd.. • Some people viewed HE in a rather stereotypical way, reflecting a narrow field of activityand focusingon the individual. • HP, on the other hand has been positioned as the more politically correct approach to challenginghealth status. 6/1/18 Concept of HP - Rakesh Singh
  • 92. Approaches to Health Education • HE is seen as a way of providing the public and in many cases risk groups with information; this information is intended to motivate them to change the behaviour that placed them at risk of developing a particular disease or set of diseases. • Diverse approaches to HE have emerged over the last century: q The two most common- preventive approach and the educational approach. q A third approach has also been implemented - the empowerment approach. 6/1/18 Concept of HP - Rakesh Singh
  • 93. The Preventive Approach • Aims to provide individuals with knowledge, facilitate a change in attitude and, if successful, to galvanize the individual into action or into the practice of preventive behaviours. • The approach supports the use of a variety of persuasive communication strategies, for example, mass media campaigns, or individual educational sessions at a local clinic, to influence behaviour change. • This approach has been criticised for assuming that knowledge leads to a change in attitude. Take the issue of a healthy diet for example: whilst I know that cream cakes and donuts are unhealthy for me, I have not eliminated them from my diet. The same could be said for smoking. As a health worker, I know smoking is bad for me and that it has a negative impact on my health. However I am not planning to give up smoking. Both examples illustrate that the relationship between knowledge, attitude and behaviour change is not straightforward. 6/1/18 Concept of HP - Rakesh Singh
  • 94. The Educational Approach • Aims to provide individuals with understanding and knowledge, facilitate a process of belief and value clarification, and develop and practise the skills to make informed decisions. • A key component of this approach is the recognition given to the value of voluntarism, i.e. that individuals should be free to make their own decisions, either now or at some future time, about their choice of action. • This kind of approach would be suitable as a basis for running workshops where individuals are or will be faced with havingto make a choice. • For example, the approach could be used in the various stages of a smoking cessation programme or in a dieting programme. It often includes a series of value clarification workshops. 6/1/18 Concept of HP - Rakesh Singh
  • 95. The Empowerment Approach • This approach supports the idea of providing individuals with an opportunity to critically reflect upon their environment, as they acquire knowledge, to clarify their values and develop skills. • This enables them to maximise their chances of managing the environmental constraints - constraints over which individuals might find it difficult to exercise some degree of control, if they did not have adequate life skills. • This approach is very much a bottom-up approach and is like the process of communitydevelopment -with the health promoter as facilitator. • An example- health promoter working with teachers to develop programmes aimed at building the self-esteem of young girls, so that they are able to actively participate in their studies and to enter into relationships with greater self-confidence. 6/1/18 Concept of HP - Rakesh Singh
  • 96. • HE models have been subject to a considerable amountofcriticism. • Concerns have been raised about their individualistic approach and their tendencytowards blamingthe victim. • For instance, how empowered are individuals to receive and to act on health education messages, when the context in which they live does not support or allowfor the necessarybehaviour change? • For example, it might be difficult for a teenager to stop smoking when adverts glamorise smoking and there is pressure on young people to smoke in order to fit into their peer group. 6/1/18 Concept of HP - Rakesh Singh
  • 97. • Although HE has achieved some success in changing lifestyle, it has been realised that changes in individual behaviour would not bring about the necessary improvements or changes that are required to change patterns of ill health or disease. • Many of the changes that were required were beyond the power of the individual. • This is where the ideas of the New Public Health and Health Promotion arose. • Let us now take a few steps back and consider how this transition came about and what other influences have shaped the course of Health Promotion as we know it today. 6/1/18 Concept of HP - Rakesh Singh
  • 99. The Early Public Health Movement in Europe • In Northern Europe, the Industrial Revolution (late 18th century in Britain), and the growing popularity and attraction of cities resulted in massive changes in population patterns and in the physical environment in which people lived. • However, this rapid industrialisation also brought with it disease and social dislocation – the disintegration of family and social structures. • In Britain, the overcrowded and unsanitary living conditions of the poor, coupled with the rise of cholera and typhoid as major causes of death, placed pressure on the government to introduce reforms or legislation to promote public health. 6/1/18 Concept of HP - Rakesh Singh
  • 100. Contd… • In 1842, Edwin Chadwick, responsible for leading a “Health of Towns Commission” and advocating for the first public health reforms, suggested that the ill health experienced by the poor was a result of poor housing, sanitation and unclean water. • His efforts resulted in the 1848 Public Health Act, which gave local authorities the powers to remedy unsanitary conditions and to require adequate drainage and sanitation in towns. • It was around this time (1854), John Snow discovered that cholera was a waterborne disease, by tracing an outbreak to a water pump in Broad Street, Soho, London. When use of the water pump was stopped, the outbreak stopped. • Experiences such as these, together with public health legislation led to the appointment of Medical Officers of Health by local authorities, to enforce public health legislation and advise on appropriate measures. 6/1/18 Concept of HP - Rakesh Singh
  • 101. • Opinions differ about whether this early public health movement evolved out of a “desire to control disease and the poor who were seen to be the cause of it, rather than by a more altruistic desire to make a society a fairer place”. • Some theorists believe that the sanitary reforms that were introduced during this time were more about ensuring that the workforce was economically active and could support an efficient capitalist economy than about the redistribution of resources and better living conditions for the poor. • Altruism or control of the poor??? 6/1/18 Concept of HP - Rakesh Singh
  • 104. Contd… • This trend – that of placing greater emphasis and value on scientific medicine rather than on social, political and environmental measures to treat and prevent ill-health continued until the early 1970’s. • You will recall that this is a medical model approach as opposed to a social or Public Health model approach. • During this era, medical advances claimed much of the credit for extending life expectancy. • After the Second World War “medical progress seemed to promise that it would eventually be able to cure most diseases”. 6/1/18 Concept of HP - Rakesh Singh
  • 105. Questioning the Medical Model • The social climate of the 1960s and 1970s was characterised by protest, activism and challenging of the status quo or existing conditions. • Examples are the Vietnam War, issues of gender equality and the Women’s Movement which were raised and protested about in public. • In addition, during the early 1970s, many countries were experiencing a crisis in health care costs. • People began to consider that whilst medicine might be good against acute illnesses like TB or pneumonia, it did not appear to have much to offer in other areas such as cancer. • The rates of cancer were still the same and there was still no cure for the disease. • Thus, value or returns from the investment in medical technology appeared to be decreasing. 6/1/18 Concept of HP - Rakesh Singh
  • 106. Contd… • Studying the growth of the population in England and Wales, showed that, apart from the smallpox vaccination, immunisation or medical therapies were unlikely to have had a significant impact on mortality in the 19th and 20th centuries. • Further, mortality was in fact declining before effective medical interventions were available. • When ranked the major contributing factors to improvements in health in order of importance.... “…limitation in family size (a behavioural change), increase in food supplies and a healthier physical environment (environmental influences) and specific preventive and therapeutic measures”. 6/1/18 Concept of HP - Rakesh Singh
  • 107. Contd… • Interventions from government authorities were critical in enabling health to be improved. • Collectively, it was established that there was importance of general standards of living and of state intervention in improving the health of populations - crucial ideas underpinning the new Public Health Movement. 6/1/18 Concept of HP - Rakesh Singh
  • 108. The New Public Health Movement • The Lalonde Report is the first major landmark in what came to be known as the New Public Health era. • In 1974, the Canadian Minister of National Health and Welfare, Marc Lalonde,publisheda report entitled A New Perspective on the Health. • This report suggested that greater emphasis should be attributed to the environment and to behavioural factors as causes of disease and death, rather than biophysical characteristics. • This was a major change from the Medical Model:in what way did it differ? 6/1/18 Concept of HP - Rakesh Singh
  • 109. Contd… • The Lalonde report described four health fields as having an influence on health and illness: 1. Medicine and health care services. 2. Lifestyle or behavioural factors. 3. The environment. 4. Human biology. 6/1/18 Concept of HP - Rakesh Singh
  • 110. Contd… • Also proposed that critical improvements within the environment, combined with changes in behaviour could lead to significant reductions in morbidityand mortality. • This report is viewed by some as a highly significant watershed in that it “… signalled the turning point in efforts to rediscover public health in developed countries”. It did so by proposing that policies focus more on the preventionofillness than on treatment and cure. • Many people consider this report as marking the beginning of the New Public Health Movement. 6/1/18 Concept of HP - Rakesh Singh
  • 111. A focus on lifestyle • Even though the Report broke with the Medical Model, the particular focus on individual behaviour or lifestyle was seen by some as cause for concern. • The focus was criticised because it was seen as narrow, failing to take into account the impact of social forces (e.g. peer influences, commercial marketing and the price of commodities)on behavioural choices. • As a result, the approach tended to ignore an individual’s social environment,or the context in which decisions were being made. • Greater emphasis was placed on individual responsibility. This led to the idea of self-imposed risk in relation to health. • In other words, people placed themselves at risk of ill-health through their choice of behaviour, e.g. drinking alcohol, taking drugs, getting pregnant unintentionallyand catchingSTDs. Contd… 6/1/18 Concept of HP - Rakesh Singh
  • 112. Contd… • HP programmes based on the approach of the Lalonde Report would have focused on persuading people to change their health-related behaviour, which placed them at risk of disease. • This focus on lifestyle was characteristic of the 1970s and brought about different approaches to creating change in individual behaviours. • These approaches drew almost exclusively on psychological theory, with little regard for the individual’s social and economic circumstances. • Well known behaviour change models such as the Health Belief Model, the Theory of Reasoned Action and the Social Learning Theory were developed during this time. 6/1/18 Concept of HP - Rakesh Singh
  • 113. Contd… • Parallel with this behavioural approach to Health Promotion, there was an increasing understanding of the structural causes of illness and health: in other words, those who did not subscribe to the ideas of Lalonde’s approach were developing one which took account of those causes that fell outside the control ofthe individual. • In line with this understanding, two significant WHO events occurred in the late 1970’s, which shaped the development ofHealth Promotion. q World Health Organisation: Global Strategy for Health for All by the Year 2000 (1977), and the International Conference on Primary Health Care, Alma-Ata (1978) 6/1/18 Concept of HP - Rakesh Singh
  • 114. Contd… • In 1977, 30th WHA decided that the main health-related goal of governments and WHO in the coming decades should be directed at ensuring that all the people of the world attain a level of health that would permit them to lead socially and economically productive lives (Global Strategyfor Health for All by the Year 2000 -HFA 2000). • This global strategy was adopted in 1981 by 34th WHA and thereby accepted as WHO policy. • Member states of the WHO were invited to formulate their national policies, strategies and plans of action for attaining this goal and to act collectivelyin formulatingregional and global strategies. 6/1/18 Concept of HP - Rakesh Singh
  • 115. Contd… • The significant feature of HFA 2000 was the recognition that the main determinants of health lay outside the health sector - namely food, water, sanitation,housing,employment etc. • This implied a global movement in which inequities between as well as within countries could be reduced. 6/1/18 Concept of HP - Rakesh Singh
  • 116. Contd… • In 1978, the International Conference on Primary Health Care at Alma-Ata defined the key to achievingthe goal of HFA 2000 as Primary Health Care. • The Declaration on Primary Health Care at Alma-Ata was an important milestone in the development ofcurrent concept of Health Promotion. • In the early 1980’s, some of the key principles of the Primary Health Care approach such as equity, community participation, a focus on prevention and the need for multi-sectoral activity, were being incorporated into international discussions about a new concept – that of Health Promotion. • Community participation or community involvement in health development is central to any discussion which focuses on Health Promotion. 6/1/18 Concept of HP - Rakesh Singh
  • 117. Principles of HP • The WHO later convened two working groups that focused on Health Promotion. • First, in 1984, a WHO working group met in Copenhagen and drew up an outline of the most important issues facing the development of Health Promotion policies and programmes. Arising from this, the WHO made explicit five key principles for Health Promotion: 1. Involves the population as a whole in the context of their everyday lives, rather than focusing on people at risk of specific diseases. 2. Directed towards action on the causes or determinants of health, to ensure that the total environment, which is beyond the control of individuals, is conducive to health. 6/1/18 Concept of HP - Rakesh Singh
  • 119. Contd… • In relation to these principles, the WHO noted that improvements in lifestyles, environmental conditions and health care will have little effect if fundamentalconditions are not met. • These conditions include peace or freedom from war, equality, satisfaction of basic needs,political commitment and publicsupport. 6/1/18 Concept of HP - Rakesh Singh
  • 120. International Conference on Health Promotion, Ottawa, Ontario, Canada (1986) • Conference produced a critical document - the Ottawa Charter for Health Promotion. • Many of the principles outlined by the WHO in their earlier working group were developed further in the Ottawa Charter. 6/1/18 Concept of HP - Rakesh Singh
  • 122. • The Ottawa Charter outlined five areas in which Health Promotion action should be directed: 1. Buildinghealthypublicpolicy. 2. Creatingsupportive environments. 3. Strengtheningcommunityaction. 4. Developingpersonal skills. 5. Re-orientinghealth services. • It identified three ways (or strategies) in which health could be promoted, namelythrough: 1. Advocacy 2. Enablement 3. Mediation 6/1/18 Concept of HP - Rakesh Singh
  • 123. Contd… • The Charter notes that HP strategies and programmes should be adapted to the local needs and that the differing social, cultural and economic systems within countries and regions should be taken into account when developingprogrammes. • The Conference tended to focus more on the needs of the industrialised countries,rather than developingcountries. • Alma Ata had a sense of abundance about it, Ottawa was characterised by restraint, reflecting the climate of the times in which the Charter was drafted. • The Charter has however been used worldwide as the basic framework around which Health Promotion activities are planned and is regarded as “...something of a mantra [or a set of guidelines] for health promotion workers”. 6/1/18 Concept of HP - Rakesh Singh
  • 124. Pre-requisites of Health (Promotion) 1. Peace 2. Shelter 3. Education 4. Food 5. Income 6. A stable eco-system 7. Sustainable resources 8. Social justice 9. Equity 6/1/18 Concept of HP - Rakesh Singh
  • 125. TASK 13 – Based on Ottawa Charter for Health Promotion a) Why is it important for health workers in developing countries to be aware of the prerequisites for health? b) How are these prerequisites for health linked to the principle of inter-sectoral collaboration proposed in the declaration of Alma Ata? c) What do the verbs to “advocate”, “enable” and “mediate” mean? d) What are some practical everyday examples of these three strategies or tools of Heath Promotion – “advocacy”, “enablement” and “mediation”? 6/1/18 Concept of HP - Rakesh Singh
  • 126. Feedback • The Charter is based on the belief that a secure foundation in society- the fundamental conditions of “peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity” - are prerequisites for health improvement. • Working in the context of a developing country, it is important for HP workers to reflect on the extent to which such prerequisites exist, and how these might affect the success or the outcome of HP interventions. • These prerequisites are linked to the principle of inter-sectoral collaboration, which is a way of helping to secure these conditions. This connection is summarised in the followingquote: “Health cannot be achieved by the health sector alone. In developing countries in particular, economic development, anti-poverty measures, food production, water, sanitation, housing, environmental protection and education all contribute to health and have the same goal of human development”(WHO-UNICEF, 1978: 40). 6/1/18 Concept of HP - Rakesh Singh
  • 128. Contd… Examples of advocacy include: • Petitions drawn up by groups of people in response to a particular issue e.g. the lack of adequate protection provided to a community by the police service or the number of rapes occurring within a region or country. • Demonstrations e.g. a group of bus drivers and owners protesting outside of parliament about current transport legislation that restricts their business. 6/1/18 Concept of HP - Rakesh Singh
  • 129. Contd… Examples of enablement include: • Trainingprogrammes and workshops. • Representative meetings e.g. all stakeholders involved in running a health clinic. Examples of mediation include: • Reaching agreement around co-ordinated action e.g. where the Health and Education Departments work together to develop health promoting schools within a local district. • Two parties coming to an agreement whereby individual interests are set aside in the interests of the health of a community e.g. after a meeting with the health department, a trucking company agrees to review their policy around the length of time drivers spend away from home and agrees to support an educational intervention for their long-distance drivers. 6/1/18 Concept of HP - Rakesh Singh
  • 130. Strategies of health promotion Advocacy • Involves a process of pressurisingor pushingfor change. • Usually aimed at changing policies, laws or regulatory measures that either work against the development of optimal health or fail to protect the health of individuals and communities. • Often seen as a process of representing the rights or needs of marginalised groups such as street children, sex workers, people suffering from a particular health condition,or poor communities. • Collaborative process, gives a voice to the needs of a community and brings these needs to the attention of appropriate decision-makers, or those that have the power to change the unhealthy policies. 6/1/18 Concept of HP - Rakesh Singh
  • 131. Contd… • Communication is an important component ofthe advocacy process. • Communication strategies include: 1. Interacting and engaging with the mass media, so as to profile the campaign and shape public debate around the problem that the campaign is addressing. 2. Producing and distributing educational media about the issue or the problem. 3. Networking with others in order to develop support for the campaign which often gives rise to the development ofcoalitions. 6/1/18 Concept of HP - Rakesh Singh
  • 133. Advocacy VS Lobbying • Advocacy is generally used to describe the broad range of activities that one would do to influence change. • Lobbying refers to the specific work one would do to influence key decision-makers (like parliamentarians and local councillors). • It is suggested that the word lobbying came to be used like this because advocates would spend many an hour waiting in the parliamentary lobby in order to catch up and meet with parliamentarians! 6/1/18 Concept of HP - Rakesh Singh
  • 134. Enablement • Enablement is a wayof workingwith others in a participative manner. • It is a process that encourages people to reflect on their own experiences and facilitates a process of learning and skills-building, which people can applyto their everydaylives. • The Ottawa Charter links enablement with equity(or fairness)in health. • For example, if we develop capacity or increase the skills of individuals or groups, be they health workers or members of the community, they will have more power to control the factors that determine their health. 6/1/18 Concept of HP - Rakesh Singh
  • 135. Mediation • Mediation is a way of coming to an agreement, of seeking reconciliation, of settingaside individualinterestsand negotiatinga common goal. • The Charter links the term mediation to co-ordinated action between different players – a concept that is often referred to when we talk about inter-sectoral action. • The motivation behind working together is that co-operation produces greater output than competition. 6/1/18 Concept of HP - Rakesh Singh
  • 137. ASSIGNMENT 1 – Analyse HP projects in terms of the Ottawa Charter Look at the five areas of action and the three strategies in the Ottawa Charter. Think about a project in your own context, and analyse and Classify each project or initiative intothe five areas of action and the three strategies. 6/1/18 Concept of HP - Rakesh Singh
  • 138. Feedback • In reality, it is difficult to distinguish into which particular action area a Health Promotion project falls or which particular strategy you are using or working with as a health promoter. • Inevitably the processes involved in one action area overlap with the work we do in another other area. • Very often we find we are working with all three strategies. • For example, in the process of developing a community campaign (advocacy), we often have to develop people’s skills or capacity in a particular area (enablement) and to facilitate agreement between the different parties involved in the campaign issue (mediation). • The important point in this exercise is to realise that for a Health Promotion project to be successful, it cannot work exclusively in one action area alone. There is a greater chance of change occurring if consideration is given to working across a range of areas of action. 6/1/18 Concept of HP - Rakesh Singh
  • 139. • Following the development of the Ottawa Charter, the WHO convened a second Working Group on Health Promotion in Developing Countries in Geneva in October 1989. • The task of this group was to explore the application of Health Promotion concepts and strategies to developing countries and to recommend specific steps for translatingthese into action. 6/1/18 Concept of HP - Rakesh Singh
  • 140. A CALL FOR ACTION • The summary statement produced by the working group meeting (convened by the WHO in 1989) for developing countries is called A Call for Action: Promoting Health in Developing Countries (WHO, 1991). It focuses on four main themes: 1. Issues (which are often in the form of challenges), that need to be considered in the field of Health Promotion. 2. The importance ofworking together to develop healthypublicpolicies. 3. Supportinggrass-roots strategies. 4. Strengthening political commitment to and national capability for Health Promotion. • The statement proposed that: “Immediate and sustained action is called for now in all nations,to move health promotion from concept to reality”. • Although developed over two decades ago, this document still provides a useful overview of some of the key issues that need to be considered in relation to Health Promotion in a developingcontext. 6/1/18 Concept of HP - Rakesh Singh
  • 142. The HP Emblem • Represents a circle with 3 wings • The main graphic elements of the HP logo are: 1. one outside circle, 2. one round spot within the circle, and 3. three wings that originate from this inner spot, one of which is breaking the outside circle. a. The outside circle, originally in red colour, is representing the goal of “Building Healthy Public Policies”, therefore symbolising the need for policies to “hold things together”. This circle is encompassing the three wings, symbolising the need to address all five key action areas of health promotion in an integrated and complementary manner. b. The round spot within the circle stands for the three basic strategies for health promotion, “enabling, mediating, and advocacy” c. The three wings represent the five key action areas for health promotion that were identified in the Ottawa Charter for Health Promotion in 1986 and were reconfirmed in the Jakarta Declaration on Leading Health Promotion into the 21st Century in 1997. 6/1/18 Concept of HP - Rakesh Singh
  • 143. Contd… More specifically: • The upper wing represents that action is needed to “strengthen community action” and to “develop personal skills”. This wing is breaking the circle to symbolise that society and communities as well as individuals are constantly changing and, therefore, the policy sphere has to constantly react and develop to reflect these changes: a “HealthyPublic Policy” is needed; • The middle wing represents that action is needed to “create supportive environmentsfor health” • The bottom wing represents that action is needed to “reorient health services” towards preventingdiseases and promotinghealth. • Overall, the logo visualises the idea that HP is a comprehensive, multi- strategyapproach. 6/1/18 Concept of HP - Rakesh Singh
  • 145. The Second International Health Promotion Conference • Held in Adelaide, Australia (1988). • Focused on the theme of healthy public policy. • At this conference, the DG of the WHO at that time explained that the main aim of developing healthy public policies was to create the preconditions for healthy living through: q closing the gap between social groups and between nations; q broadening people’s choices to make healthy their choices the easiest and most possible, and q ensuring supportive social environments. • The importance of community participation and collaboration between all sectors of government were emphasised as crucial aspects of healthy public policy. 6/1/18 Concept of HP - Rakesh Singh
  • 146. The Third International Health Promotion Conference • Held in Sundsvall,Sweden in 1991. • Focused on linkingenvironmentalissues directlyto human health. • Emphasised that Health Promotion has been, and should be concerned with preservingand protectingnatural environments. • An important link was thus made at this international conference between those activities concerned with the promotion of health within communities and those activities that focus on protecting the natural environment. 6/1/18 Concept of HP - Rakesh Singh
  • 147. United Nations Conference on Environment and Development (The Earth Summit) • Held in Rio de Janeiro,Brazil in 1992. • One of the outcomes of this conference was the development of a detailed action plan outlining how member states could work towards sustainable development. • By sustainable development they meant development which meets the needs of the present without compromising the ability of future generations to meet their own needs. • The action plan specifically highlights the role of local government in achievingthis sustainability. 6/1/18 Concept of HP - Rakesh Singh
  • 148. The Fourth International Health Promotion Conference • Held in Jakarta,Indonesia in 1997. • First time it had been held in a developingcountry. • Focused on identifying directions and strategies to address the challenges of promotinghealth in the 21st Century. • The main outcome of the conference was the Jakarta Declaration. • In the Declaration, emphasis was placed on the importance of developing new alliances and partnerships, for example between private and public, and within government and non-government agencies. • In addition,the declaration adopts a settings approach to Health Promotion. • Settings refers to an approach to Health Promotion that focuses on a place or a setting in which people gather, such as a school or a workplace, as opposed to an illness or symptom. • Health promoters were urged to build new alliances for health, including private sector partnerships. 6/1/18 Concept of HP - Rakesh Singh
  • 149. Contd… • In practice, this could mean that the local government structure, in collaboration with the local community, identifies the major social, economic and environmental issues that are going to pose substantial risks to the environment and to publichealth. • They then develop an integrated action plan to address the key issues, both in the short and long term. • Another approach might be for all stakeholders to identify key environmental and public health goals that they would want incorporated into the local government management plans, such as accessing affordable housing, improving public transport, and ensuring community safety. 6/1/18 Concept of HP - Rakesh Singh
  • 150. Priorities identified by JD 1. Promote social responsibilityfor health 2. Increase investments for health development 3. Consolidate and expand partnerships for health 4. Increase communitycapacityand empower the individual 5. Secure an infrastructure for health promotion 6/1/18 Concept of HP - Rakesh Singh
  • 151. The Fifth Global Conference on Health Promotion • Took place in Mexico City from the 5-9th June 2000. • It was entitled Bridging the Equity Gap. • It had the followingobjectives: q To show how Health Promotion makes a difference to health and quality of life, particularlyfor those livingin adverse conditions. q To place health high on the development agenda within international, national and local agencies. q To stimulate partnerships for health between different sectors and at all levels of society. 6/1/18 Concept of HP - Rakesh Singh
  • 152. Brainstorm • In terms of the June 2000 HP conference,what is the significance of: a) The switch to calling it a “global” rather than an “international” conference? b) The conference objectives and what they suggest about the future direction ofHP? 6/1/18 Concept of HP - Rakesh Singh
  • 153. Feedback a) The term “global” signifies that the conference is now bigger in scope, involvingcountries from all over the world,rather than just some nations. b) The conference objectives do not, however, introduce an entirely new agenda for HP. Instead theystress new priorities: • The role of HP in promoting development at all levels, particularly with regard to poor countries. • CollaborationaroundHP at all levels. 6/1/18 Concept of HP - Rakesh Singh
  • 154. • The Bangkok Charter for HP (Thailand), 2005: New Context, Globalization (advocate for health based on human rights, invest in sustainable policies, actions and infrastructure, build capacity for policy development, leadership, HP practice, knowledge transfer and research, and health literacy; regulate and legislate to ensure a high level of protection, partner and build alliance to create sustainable actions). • Nairobi, 2009: Bridging the implementation gap (multiple participatory processes, urgency to close the implementation gap in health and development through HP, importance of HP as an integrative, cost- effective strategy, and as an essential component of health systems primed to respond adequatelyto emergingconcerns). 6/1/18 Concept of HP - Rakesh Singh Further Discourse in HP
  • 155. Contd… • Helsinki, Finland, 2013: Theme: Health in all policies (Inter-sectoral action – action beyond health sector; its focus was on implementation, the “how- to”). • Shanghai, 2016: (health and wellbeing are essential to achieving sustainable development, Good governance is crucial for health, Cities and communities are critical settings for health, Health literacy empowers and drives equity, accelerate the implementation of the SDGs through increased political commitment and financialinvestment in HP) 6/1/18 Concept of HP - Rakesh Singh
  • 156. ASSIGNMENT 2 – Assess the role of the private sector as outlined in the Jakarta Declaration Read the Jakarta Declaration on Health Promotion into the 21st Century: a) What role you think the private sector or the sector which works for profit could playin a Health Promotion project at a local or district level? b) What do you think some of the difficulties might be in working with the private or business sector at a local level? 6/1/18 Concept of HP - Rakesh Singh
  • 157. Feedback • If you are developing or managing a Health Promotion project at a local level, it is likely that you would set up a steering committee or an inter-sectoral team to co-ordinate the project. • Like other role players in the district, a representative from the private sector or business sector would be a member of this committee. • Together the team would develop the vision for the project and start defining project objectives and activities. A private sector representative might be able to contribute to the project by: q Providing resources such as a meeting space for the group and a venue for workshops, covering the costs of printing materials or minutes of the meetings. q Providing skills and training in relation to project design and development, such as strategicplanningprocesses or budgeting. q Providing contacts and links with other businesses or private sector institutions or networks. q Supporting the implementation of the project on the ground e.g. by providing the commitment and resources to implement the Health Promotion project within their respective workplaces. 6/1/18 Concept of HP - Rakesh Singh
  • 158. Contd… • Some of the potential problems might be that private sector representatives: q Have less time to commit to the development ofthe project. q Stipulate that there are specific requirements attached to the resources they contribute to the project or the development process. q Might have a different understandingofthe concept of Health Promotion. q Might be pressurised to produce noticeable or tangible results from the project early on in the process, thus reducing the level of community involvement. 6/1/18 Concept of HP - Rakesh Singh
  • 160. Preventive Health Services • These include medical services, which aim to prevent ill-health through immunization, family planning and personal health checks, as well as wider preventive health services such as child protection services for children at risk of child abuse. 6/1/18 Concept of HP - Rakesh Singh
  • 161. Community-based work • This is a “bottom up” approach to Health Promotion, working with and for people. • It involves communities in health works such as local campaigns for better facilities. • It includes community development, which is essentially about communities identifying their own health needs and taking action to address them. 6/1/18 Concept of HP - Rakesh Singh
  • 162. Organizational development • This is about developing and implementing policies within organisations to promote the health of staffand customers. • Examples include implementing policies on equal opportunities or providinghealthyfood choices in staffdiningrooms. 6/1/18 Concept of HP - Rakesh Singh
  • 163. Healthy public policies • This involves statutory and voluntary agencies, professionals and the publicworkingtogether to develop changes in the conditions ofliving. • It is about seeing the implication for health in policies associated with housing,employment,transport and leisure. 6/1/18 Concept of HP - Rakesh Singh
  • 164. Environmental health measures • This is about making the physical environment conducive to health, whether at home, work or in publicplaces. • It includes traditional public health measures such as providing clean food and water, controlling pollution, as well as working on newer issues such as providing smoke free areas in pubs or taverns and controlling the use of environmentallydamagingchemicals. 6/1/18 Concept of HP - Rakesh Singh
  • 165. Economic and regulatory activities • This includes political and educational activity directed at politicians, policymakers and planners. • It involves lobbying for and implementing legislative changes, such as food labelling regulations and advocating for financial measures such as an increase in tobacco legislation. 6/1/18 Concept of HP - Rakesh Singh
  • 166. Health education programmes • These are planned opportunities for people to learn about health and to undertake voluntarychanges in their behaviour. • Such programmes may include providing information, exploring values and attitudes, making health decisions and acquiring skills to enable behaviour change to take place. • They involve developing self-esteem and self- empowerment so that people are enabled to take action about their health. • They can happen on a one-to-one level such as health worker to client sessions, in a group, or by means of reaching large audiences through the mass media and health exhibitions. 6/1/18 Concept of HP - Rakesh Singh