STRATEGY AND APPROACHES OF

EFFECTIVE HEALTH PROMOTION

PHOP 4
A.Y 2017/2018
What is Health?
• Health was defined by the World Health Organization (WHO) in
1947 as “a state of complete physical, mental and social well-
being not merely the absence of disease or infirmity”.
• In 1998 the definition was updated to emphasize social and
personal resources plus physical capabilities

World Health Organization Interim Commission. Bulletin of

the World Health Organization (WHO) 1947/48; 1(1): 1-4.
What is health Promotion?
• The most well-known definition of health promotion is that of the
World Health Organization’s Ottawa Charter (1986): Health
promotion is the process of enabling people to increase control
over, and to improve their health

• This definition was slightly modified in 2005, in WHO’s Bangkok

Charter for Health Promotion in a Globalised World to: Health
promotion is the process of enabling people to increase control
over their health and its determinants, and thereby improve
their health.
Guideline for the development of effective
health promotion innovations

• The First International Conference on Health Promotion was held in

Ottawa, Canada in 1986
• The outcome of the conference was the development and
ratification of the WHO Ottawa Charter for health Promotion.
• The five principles of the charter were:
1. to build healthy public policy;
2. to create supportive environments;
3. to strengthen community action;
4. to develop personal skills; and
5. to reorient health services.
 Prerequisites for Health
The fundamental conditions and
resources for health are:
1. peace,
2. shelter,
3. education,
4. food,
5. income,
6. a stable eco-system,
7. sustainable resources,
8. social justice, and equity.
Improvement in health requires a
secure foundation in these basic
prerequisites.

http://www.who.int/healthpromotion/conferences/previous
/ottawa/en/index.html
 • Health education programs have
been informed by several
theoretical models of health
behavior change including the:
Development of • Health Belief Model,
Behavior • the Theory of Reasoned Action,
and
Sciences directly • the Operant Learning Theory
change the (Skinner, 1974).
Health • Over the past 10 years, however,
Promotion one model, the Social Cognitive
Strategies Theory (SCT) has become perhaps
the dominant theoretical
framework for health education
(Bandura, 1986; Bandura, 1995;
Perry et al., 1990)
Increase demand and practice of
Health Promotion Worldwide
• The last decade or so has seen a
marked increase in the amount
of health educational/health
promotional activities

J Adv Nurs. 2001 Nov;36(3):417-25.

Health Promotion in PHC
• Electronic modes of communication, education and training are
now commonplace in many medical practices. The PHC sector has
a small window of opportunity in which to become leaders within
the current model of continuity of care by establishing their
role as innovators in the prevention,
treatment and management of disease. Not only
will this make their own jobs easier, it has the potential to
significantly impact patient outcomes
Health promotion innovation in primary health care Alexandra McManus Curtin Health Innovation Research Institute
(CHIRI), Curtin University, Perth, Australia
Australasian Medical Journal [AMJ 2013, 6, 1, 15-18]
Framework of Health Promotion

McManus A. Health promotion innovation in primary health care. AMJ 2013, 6, 1, 15-18.
http//dx.doi.org/10.4066/AMJ.2013.1578.
Multi-Source Method for Developing
Health Promotion Programs

Public Health Nurs. 2010 Mar-Apr; 27(2): 188–

195.
What is the best model of Health
Promotion?
• Healthpromotion strategies and programmes should be adapted
to the local needs and possibilities of individual countries and
regions to take into account differing social, cultural and economic
systems.
WHO Global Health Promotion
Conferences
Priorities of Strategy of the Health
Promotion in 21st Century
1. Promote Social Responsibility for Health
2. Increase investment for health Development
3. Consolidate and Expand partnership for Health
4. Increase community capacity and empower the individual
5. Secure an Infrastructure of Health Promotion

www.who.int/healthpromotion/milestones_Jakarta.pdf
MODELS OF
HEALTH
PROMOTION
Development of HP Models
• While the definition of health promotion has been universally
adopted, there have been a number of different approaches to
promoting health. Over the past 30 years, three key models of
health have influenced health promotion.
1. The biomedical model of health (pre-1970s)
2. The social model of health (from 1970s onwards)
3. The ecological model of health (from late 1970s onwards)

https://www.vichealth.vic.gov.au/media-and-resources/vce-
resources/defining-health-promotion
The biomedical model of health
(pre-1970s)
• Focuses on risk behaviours and healthy
lifestyles
• emphasises health education – changing
knowledge, attitudes and skills
• focuses on individual responsibility
• treats people in isolation of their
environments
The social model of
health (from 1970s
onwards)
• addresses the broader determinants
of health
• involves inter-sectoral collaboration
• acts to reduce social inequities
• empowers individuals and
communities
• acts to enable access to health care
The ecological model of
health (from late 1970s
onwards)
• acknowledges the reciprocal relationship
between health-related behaviours and
the environments in which people live,
work and play (behaviour does not occur
in a vacuum)
• considers the environment is made up of
different subsystems – micro, meso, exo
and macro
• emphasises the relationships and
dependencies between these
subsystems
• is comprehensive and multi-faceted,
using a shared framework for change at
individual and environmental levels
 HEALTH
PROMOTION
APPROACHES
 Medical or preventative

Main Behavioral change

approaches Educational
to health
promotion Empowerment
Social change
01 02 03 04
To prevent disease To insure that To help people To change polices
people are well acquire the skills and and environments in
informed and are confidence to take order to facilitate
able to make health greater control over healthy choices
choices their health

These approaches have

different objectives
TOP-DOWN VS. BOTTOM-UP
• TOP DOWN
Priorities set by health promoters
who have the power and resources to
make decisions and impose ideas of
what should be done
• BOTTOM UP
Priorities are set by people
themselves identifying issues they
perceive as relevant
• TOP DOWN WITH
PARTICIPATORY/EMPOWERME
NT
 THE MEDICAL
OR
PREVENTATIVE
APPROACH
 THE MEDICAL OR PREVENTATIVE
APPROACH

Aims
• Reduce morbidity and premature mortality
• Target: whole populations or high risk groups
• Promotion of medical intervention to prevent
ill-health
 THE MEDICAL OR PREVENTATIVE
APPROACH

Levels of interventions

Primary prevention – prevention of onset of

disease, e.g. immunization; encouraging non
smoking

Secondary prevention – preventing progression

of disease, e.g. Screening

Tertiary prevention – reducing further disability

and suffering in those already ill; e.g.
rehabilitation, patient éducation, palliative care
 THE MEDICAL OR PREVENTATIVE
APPROACH

Popularity of medical approach

• Uses scientific methods, e.g. epidemiology
• Prevention and early detection of disease is cheaper than
treatment
• Top-down approach, i.e. led by experts, this kind of activity
reinforces authority of health professionals who are viewed as
having necessary knowledge to achieve results
• Highly successful examples in the past, e.g. in Indonesia eradication
of smallpox, Poliovirus (PIN), Fillariasis
 THE MEDICAL OR PREVENTATIVE
APPROACH

Disadvantages
• Focuses on the absence of disease rather
than on promoting positive health
• Based on a medical definition of health
• Ignores the social and environmental
dimensions of health
• Encourages dependency on medical
knowledge and compliance with treatments
• Removes health decisions from
nonprofessional people
 THE MEDICAL OR PREVENTATIVE
APPROACH

Methods
• Preventive procedures need to be based on a sound rationale
derived from epidemiological evidence
• Having an infrastructure capable of delivering screening or
immunization programs, e.g. Trained personnel, equipment and
laboratory facilities, record keeping facilities, effective and safe
vaccine
 THE MEDICAL OR PREVENTATIVE
APPROACH

Evaluation of medical approach

• Short term evaluation
• Increasing in percentage of target population being screened or
immunized
• Antibody Titer measurement (expensive and takes time)

• Long term evaluation

• Reduction in disease rates and associated mortality
BEHAVIOR CHANGE
APPROACH
 BEHAVIOR CHANGE APPROACH

Aims

04 05
02 03 It is people’s
Involves a
change in
01
Encourages
Views health
as a property
People can
make real
responsibilit
y to take
attitude
individuals to improvemen followed by
of individuals action to a change in
adopt ts to their look after
healthy health by behavior
themselves
behaviors choosing to
which change
improve lifestyle
health
 BEHAVIOR CHANGE APPROACH

Disadvantages
• Depends on person’s readiness to take action
• Complex relationship between individual behavior and social and environmental factors
• Behavior may be a response to a persons’ living conditions which may be beyond individual control (e.g.
Poverty, unemployment) or SOCIAL DETERMINANT
 BEHAVIOR CHANGE APPROACH

Methods

Campaigns to persuade people e.g.

• Not to smoke
• To adopt a healthy diet
• To undertake regular exercise, etc.
Targeted towards individuals

May use mass-media to reach them

 BEHAVIOR CHANGE APPROACH

Evaluation
• Theoretically it would appear simple by asking: “Has the health
behavior changed after the intervention?”
• However, there are two main problems
• Change may become apparent only after a long period

• Difficult to determine whether behavior change was due to health

promotion intervention or other motives
THE EDUCATIONAL
APPROACH
 THE EDUCATIONAL APPROACH

Aims
• To enable people to make an informed choice about their health
behavior by
• providing knowledge and information
• developing the necessary skills

• Not similar the behavioral approach, it does NOT try to persuade or

motivate change in a particular direction
• OUTCOME is client’s voluntary choice which may be different from
the one preferred by health promoter
 THE EDUCATIONAL APPROACH

Disadvantages
• ASSUMES THAT:
Increase in knowledge will change in attitudes and the final result is
behavior change
BUT:
• Voluntary behavior change may be restricted by social and
economic factors
• Health related decisions are very complex
 THE EDUCATIONAL APPROACH

Methods
• Aspects of learning:
• Cognitive Aspect (information and understanding)
• Affective Aspect (attitudes and feelings)
• Behavioral Aspect (skills)
 THE EDUCATIONAL APPROACH

Aspects of learning
• Cognitive Aspect - Provision of information about
causes and effects of health-related behaviors
• Provision of leaflets/booklets
• Visual displays
• One-to-one advice
• Affective Aspect - Provision of opportunities for clients
to share and explore their attitudes and feelings
• One-to-one counseling
• Group discussions
• Behavioral Aspect - Helping clients develop decision-
making skills required for healthy living
• Exploring Real life situations
• Role Play
• Examples: reaction when offered a drink / cigarette / drugs;
negotiating contraception use
 THE EDUCATIONAL APPROACH

Evaluation
• Increase in knowledge is easy to measure (exam, pre-post
questionnaire..)
• HOWEVER, Knowledge alone is insufficient to change behavior
• Knowledge is rarely translated into behavior
EMPOWERMENT APPROACH
 Empowerment approach

•WHO defined health promotion as

“enabling people to gain control over
their lives” (empowerment)

em·pow·er·ment (əmˈpouərmənt/) is the process of becoming

stronger and more confident, especially in controlling one's life and
claiming one's rights.
 Empowerment approach

Aims
• Helps people identify their own concerns and gain the skills and
confidence necessary to act upon them
• This is the only approach to use a ‘bottom-up’ (rather than ‘top-
down’) approach
• For people to be empowered they need to:
1. Recognize and understand their powerlessness
2. Feel strongly enough about their situation to want to change it
3. Feel capable of changing the situation by having information, support
and life skills
 Empowerment approach

Aims (Cont.)
• Clients have the right to set their own agenda
• Health promoter plays the role of a facilitator rather than that of
an expert, he/she Initiates the process but then withdraws from the
situation
• Empowerment may involve both self-empowerment and
community empowerment
• Self-empowerment:
• Based on counseling
• Uses non-directive ways
• Increase person’s control over his/her own live
 Empowerment approach

Disadvantages
• Results are vague and hard to quantify compared with those of
other approaches
• Health promoter may feel uncomfortable in handing over his
expert role
 Empowerment approach

Methods
• Examples of methods used in empowerment approach:
• Nurses working with patients to develop a care plan
• Teachers working with students to raise their self-esteem
• Health workers of Puskesmas facilitate the informal leaders (RT/RW) to
make a healthy environment need assessment program
 Empowerment approach

Evaluation
• Outcome evaluation: the extent to witch specific aims have been met
• Process evaluation: The degree to which the group has been
empowered as a result of the intervention
• Evaluation includes qualitative methods that reveal people's
perceptions and beliefs and quantitative methods that demonstrate
the outcome such as behavioral change
• HOWEVER, Usually empowerment is a long term process and
difficult to conclude that changes are due to the intervention rather
than some other factor
SOCIAL CHANGE APPROACH
 SOCIAL CHANGE APPROACH

Aims
• Radical approach which aims to change society not individual
behavior
• Aims to bring changes in the physical, economic and social
environment
• Healthy choice to become the easier choice in terms of cost,
availability and accessibility
• Targeted towards groups and populations
 SOCIAL CHANGE APPROACH

Disadvantages
• It may require major structural changes
• Vulnerable to official disapprovals
• Requires political support from the highest level, e.g. through
legislation
• Needs support of the public
 SOCIAL CHANGE APPROACH

Methods
• Public needs to be informed of its importance
• Health promoter involved in awareness raising, policy planning,
negotiating and implementation
• Example: changes in the pricing structures such as increasing the
tobacco/cigarette tax to rise the price of cigarette in order to
minimize the consumption of tobacco
 SOCIAL CHANGE APPROACH

Evaluation
• Outcome evaluation:
• changes in laws or regulations, e.g. Smoking bans, food labeling,
applying taxes / subsidies on certain types of foods
• Improvement in the profile of health issues on common agendas
• May be difficult to prove link with health promotion interventions
as change is usually a lengthy process
THE FIVE APPROACHES
EXAMPLES RELATED TO SMOKING

Based on Ewles and Simnet (1992: 36)

The medical approach

• AIM: Free from lung disease, heart

disease and other smoking related
disorders

• ACTIVITY: Encourage people to

seek early detection and
treatment of smoking related
disorders
Behavioral change approach

• AIM: Behavior changes from smoking to

not smoking

• ACTIVITY: Persuasive education to

– prevent non-smokers from starting to
smoke
– persuade smokers to stop
Educational approach

• AIM: Clients understand effects of smoking on

health and will make a decision whether to
smoke or not and act on their decision

• ACTIVITY: Giving information to clients about

effects of smoking
• Helping them explore their values and
attitudes and come to a decision
• Helping them learn how to stop smoking if
they want to
The empowerment
approach

AIM: Anti-smoking issue is

considered only if clients
identify it as a concern

ACTIVITY: Clients identify what,

if anything, they want to know
and do about it
Social change approach

• AIM: Make smoking socially unacceptable so

it is easier not to smoke than to smoke

• ACTIVITY
– No smoking policy in all public places
– Cigarette sales less accessible
– Promotion of non-smoking as a social norm
– Limiting and challenging tobacco
advertisements and sports sponsorships
HATUR NUHUN