Seminar 1

Principles and Practices of Health

Promotion
 Learning objectives
To be able to describe the principles, different
approaches, and strategies used in Health
Promotion
To be able to identify common issues or problems
related to health promotion like communication
skills, knowledge of culture and social issues etc.
To be able to discuss dynamic changes occuring
in behaviour
To be able to design, implement and evaluation
of an appropriate health promotion program
 What is health promotion?
Health promotion is the process of enabling
people to increase control over, and to improve,
their health. It is a positive concept emphasising
personal, social, political, and institutional
resources, as well as physical capacities.

WHO, 1990, Health Promotion Glossary

 World Health Organisation Principles
of Health Promotion
Empowerment - a way of working to enable people to gain greater control over
decisions and actions affecting their health.

Participative - where people take an active part in decision making.

Holistic - taking account of the separate influences on health and the interaction of
these dimensions.

Equitable - ensuring fairness of outcomes for service users.

Intersectoral - working in partnership with other relevant agencies/organisations.

Sustainable - ensuring that the outcomes of health promotion activities are

sustainable in the long term.

Multi Strategy - working on a number of strategy areas such as programmes, policy.

 Health promotion goals
Healthy Population
Healthy Lifestyle
Healthy Environment
 Healthy Population
Encourages initiative that focus on the health
needs and contributions of people at every life
stage

Needs of every individual varies according to

age and gender
 Healthy Lifestyle
Behaviour and decisions that can lead to a
healthier life

Better nutrition, no smoking and exercise

regularly
 Healthy Environment
Creating social, economic and environmental
conditions for good health

Challenges include, poverty, illiteracy, and

endemic diseases
 Who promotes health?
International organization
Health authorities
NGOs
Primary health care team
Private physician
Other health professions, eg. Nurses
Religious organisations
YOU
Health Promotion according to Ottawa
Charter 1986
Developing Personal Skills

Creating Supportive Environments

Strengthening Community Action

Developing Public Policy

Re- orienting the Health Services.

APPROACHES IN HEALTH PROMOTION
Medical
Behaviour Change
Educational
Empowerment
Social Change

(Health Education Unit Ministry of Health

Malaysia)
 MEDICAL APPROACH
Aim
To reduce morbidity and premature mortality
To ensure freedom from diseases and disability

Methods : Medical intervention, risk education

Activity:
Uses medical intervention to prevent ill-health or premature death.
Eg. - Immunization, screening, fluoridation.

Evaluation: Reduction in disease rates & associated mortality.

 BEHAVIOUR CHANGE
Aim
- Encourage individuals to adopt healthy behaviors.
- Views health as the responsibility of individuals.

Methods :
- Communication, Education, Persuasion, motivation

Evaluation
- Behavior change after the intervention, but
The behavior change is only apparent after a long time.
Difficult to isolate any behavior change as attributable to a
health promotion intervention
 EDUCATIONAL APPROACH
Aim
- To provide knowledge and information.
- To develop the necessary skills for informed choice.
- The outcome is clients voluntary choice.
Methods
1. Information-giving through interpersonal channels, small groups
and mass media, so that the clients can make an informed choice.
2. Group discussion for sharing and exploring health attitudes
3. Role play for decision-making and negotiating skills

Evaluation
- Knowledge, attitude and practice.
 EMPOWERMENT
Aim
-Helps people to identify their own needs and
concerns, and gain the necessary skills and
confidence to act upon them.
Methods
- Counselling, problem solving, community
development, advocacy, public participation
 Two types of empowerment:
1. Self-empowerment
- based on counselling and aimed at increasing
peoples control over their own lives.

2. Community empowerment
- related to community development to create
active, participating communities which are able
to change the world about them through a
programme of action.
 Evaluation includes:
1. Outcome evaluation - the extent to which
specific aims have been met.
Process evaluation - the degree to which the
individual and community have been empowered
as a result of the intervention.

Difficult because empowerment is long term.

Results are hard to specify and quantify
 SOCIAL CHANGE
Aim
- To bring about changes in physical, social, and
economic environment, which enables people
to enjoy better health
- Radical health promotion - makes the
environment supportive of health.
- To make the healthy choice the easier choice.
- The focus is on changing society, not on
changing the behaviour of individuals.
 Methods
- Focus on shaping the health environment
development of healthy public policies and
legislation
fiscal measures
creating supportive social and physical
environments
lobbying/advocacy
 Strategies for Health Promotion
according to Ottawa Charter
1) Enabling all people to achieve their full
health potential
2) Mediating between the different interests in
society in the pursuit of health
3) Advocacy for health to create the essential
conditions for health
 ENABLE
Health promotion focuses on achieving equity in
health.
Health promotion action aims at reducing
differences in current health status and ensuring
equal opportunities and resources to enable all
people to achieve their fullest health potential
This includes a secure foundation in a supportive
environment, access to information, life skills and
opportunities for making healthy choices
 MEDIATE
The prerequisites and prospects for health
cannot be ensured by the health sector alone
More importantly, health promotion
demands coordinated action by all concerned:
by governments, by health and other social
and economic sectors, by nongovernmental
and voluntary organization, by local
authorities, by industry and by the media.
 ADVOCACY
Good health is a major resource for social,
economic and personal development and an
important dimension of quality of life.
Political, economic, social, cultural,
environmental, behavioural and biological factors
can all favour health or be harmful to it.
Health promotion action aims at making these
conditions favourable through advocacy for
health.
 ADVOCATE
- political, economic,
social, cultural
environmental behavior
and biological sector

MEDIATE
- Health promotion
demands coordinated
action
- Should be adapted to the
local need and possibilities
of individuals, countries
and religion to take into
account differing social,
cultural, and economic
systems
ENABLE
- Reducing differences
in current health
status and ensuring
equal opportunities
and resources to
enable all people to
achieve their fullest
health potential
Problems related to Health Promotion
Communication
-Language barrier, poor educational status

Poor compliance

Place
- Remote areas in the rural region

Culture and religion

-not accept certain changes in their lifestyle and health status

Knowledge
-poor acquisition of knowledge
 DYNAMIC CHANGES
OCCURING IN BEHAVIOUR
Theories that explain health behaviour and
health behaviour change by focusing on the
individual
Health Belief Model (HBM)
Stages of Change (Trans-theoretical) Model
[TTM]
Social Cognitive Theory (SCT)
Precede-Proceed Model
 HEALTH BELIEF MODEL (HBM)
is a psychological model that attempts to explain and predict health
behaviors.

This is done by focusing on the attitudes and beliefs of individuals.

First theory that was developed in 1950s by psychologists of US

Public Health Services. It was developed in response to the failure
of a free tuberculosis (TB) health screening program.

Since then, the HBM has been adapted to explore a variety of long-
and short-term health behaviors, including sexual risk behaviors
and the transmission of HIV/AIDS
The HBM is based on the understanding that a person will
take a health-related action if that person:
1. feels that a negative health condition can be avoided
(eg: HIV)
2. has a positive expectation that by taking a recommended
action, he/she will avoid a negative health condition
(eg: using condoms will be effective at preventing HIV)
3. believes that he/she can successfully take a recommended
health action
(eg: he/she can use condoms comfortable and with
confidence)
 The HBM was spelled out in terms of 4constructs representing the
perceived threat and net benefits:Perceived
susceptibility, perceived severity, perceived benefits, and
perceived barriers.

These concepts were proposed as accounting for people's

readiness to act.

An added concept, cues to action, would activate that readiness

and stimulate overt behavior.

A recent addition to the HBM is the concept of self-efficacy, or

one's confidence in the ability to successfully perform an action.
 CONCEPTS DEFINITION APPLICATION
Perceived One's opinion of chances of getting a Define population(s) at risk, risk levels;
condition personalize risk based on a person's
Susceptibility
features or behavior; heighten perceived
susceptibility if too low.

Perceived One's opinion of how serious a Specify consequences of the risk and the
condition and its consequences are condition
Severity

Perceived One's belief in the efficacy of the Define action to take; how, where, when;
advised action to reduce risk or clarify the positive effects to be expected.
Benefits seriousness of impact

Perceived One's opinion of the tangible and Identify and reduce barriers through
psychological costs of the advised reassurance, incentives, assistance.
Barriers action

Cues to Action Strategies to activate "readiness" Provide how-to information, promote

awareness, reminders.

Confidence in one's ability to take Provide training, guidance in performing

Self-Efficacy
action action.
 Trans-theoretical Model
is an integrative, biopsychosocial model to
conceptualize the process of intentional behavior
change.

Studies of change have found that people move

through a series of stages when modifying
behavior.

the time a person can stay in each stage is

variable, the tasks required to move to the next
stage are not.
 The Stages of Change Model
Precontemplation: this describes individuals who are
not even considering changing behaviour or are
consciously intending not to change
Contemplation: the stage at which a person considers
making a change to a specific behaviour
Determination, or preparation: the stage at which a
person makes a serious commitment to change
Action: the stage at which behaviour change is initiated
Maintenance: sustaining the change, and achievement
of predictable health gains
Relapse may also be the fifth stage where individual
returns to the pre-change condition
 Social Cognitive Theory
Proposes that learning occurs in a social context
with a dynamic and reciprocal interaction of the
person, environment and behavior.
Unique features of SCT is the emphasis on social
influence and its emphasis on external and
internal social reinforcement.
SCT considers the unique way in which individuals
acquire and maintain behavior , while also
considering the social environment in which
individuals perform the behavior
 Goal of SCT is to explain how people regulate their
behaviour through control and reinforcement to achieve
goal-directed behavior that can be maintained over time.
6 constructs:
Reciprocal determinism: This is central concept of SCT. This
refers to dynamic and reciprocal interaction of person
(individual with set of learned experiences), environment
(external social context), and behavior ( response to stimuli
to achieve goals)
Behavioral capability: This refers to a persons actual ability
to perform a behavior through essential knowledge and
skills. In order to successfully perform a behavior, a person
must know what to do and how to do it
 Observational learning: This asserts that people can witness and
observe a behavior conducted by others, and then reproduce the
actions. This is often exhibited through modeling of behaviors. If
individuals see successful demonstration of a behavior, they can also
complete the behavior successfully.

Reinforcements: this refers to the internal or external responses to a

persons behavior that affect the likelihood of continuing or
discontinuing the behavior. It can be self-initiated or in the
environment, and can be positive or negative

Expectations: refers to anticipated consequences of a persons

behavior. Outcome expectations can be health-related or non-health
related. People can anticipate the consequences of their actions
before engaging in the behavior, and these anticipated consequences
can influence successful completion of behavior, this expectations
derived largely form previous experiences

Self-efficacy: refers to the level of a persons confidence in his or her

ability to successfully perform a behavior.it is influenced by a persons
specific capabilities and other individuals factors, as well as
environmental factors
 Precede-Proceed Model
The PRECEDE-PROCEED model is a tool for
designing, implementing, and evaluating health
behavior change programs. It was developed for
use in public health.
Originally Developed in the 1970s by Green and
colleagues
It provides a comprehensive structure for
assessing health and quality of life needs, and for
designing, implementing, and evaluating health
promotion and other public health programs to
meet those needs.
 Health behavior is regarded as being influenced
by both individual and environmental factors, and
hence has two distinct parts
1. First is an "educational diagnosis" PRECEDE, an
acronym for Predisposing, Reinforcing and
Enabling Constructs in Educational Diagnosis
and Evaluation.
2. Second is an "ecological diagnosis" PROCEED,
for Policy, Regulatory, and Organizational
Constructs in Educational and Environmental
Development
 The PRECEDEPROCEED planning model
consists of four planning phases, one
implementation phase, and 3 evaluation
phases
Phase 1: social Phase 6: Process
Precede

Phases
Proceed
Proceed Phase
diagnosis Phase 5: Evaluation
Phase 2:
Epidemiological,
Implement Phase 7: Impact
Evaluation
Behavioral & ation
Phases

Environmental Phase 8: Outcome

Diagnosis Evaluation
Phase 3: Educational
& Ecological
Diagnosis
Phase 4:
Administrative &
Policy Diagnosis
Phase 1: Social Diagnosis
Understanding the community through multiple data
collection activities
articulates the communities needs and desires while
considering the communities problem solving capacity,
strengths, and resources, and the readiness to change

Phase 2: Epidemiological, Behavioral &

Environmental Diagnosis
Identify the health priorities and their behavioral and
environmental determinants.
Educational & Ecological Diagnosis
Once the behavioral and environmental factors
are identified and interventions are selected,
planners can start to work on selecting factors
that if modified will be most likely to result in
behavior change and can sustain this change
process
These factors are classified as predisposing
factors, enabling factors, and reinforcing factors
 Predisposing factors any characteristics of a person
or population that motivates behavior prior to or
during the occurrence of that behavior. They include an
individual's knowledge, beliefs, values, and attitudes.
Enabling factors those characteristics of the
environment that facilitate action and any skill or
resource required to attain specific behavior.
Eg:services, availability and accesibility resources
Reinforcing factors rewards or punishments
following or anticipated as a consequence of a
behavior. Eg:social support, peer support
Administrative & Policy Diagnosis
This phase focuses on the administrative and
organizational concerns, which must be
addressed prior to program implementation
includes assessment of resources, development
and allocation of budget, looking at
organizational barriers, and coordination of the
program with all other departments, including
external organizations and the community.
: Implementation
Implement all the resources into the programs

Phase 6: Process Evaluation

Evaluate whether the program is being implemented
according to the protocol, and determines whether the
objectives of the program are being met
Phase 7: Impact Evaluation
measures the effectiveness of the program with regards to
the intermediate objectives as well as the changes in
predisposing, enabling, and reinforcing factors
Phase 8: Outcome Evaluation
measures change in terms of overall objectives and
changes in health and social benefits or the quality of life
determine effect the program had in the health and quality
of life of the community