6. Health Education and Promotion in the UK
(This is the sixth in a new series looking at different aspects of health and social care in the UK, which I originally wrote back in 2016. I hope you find it interesting!)
Models of health and the underpinning theoretical perspectives related to health promotion
The World Health Organization defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (WHO, 1948 p.100). This definition, has been much criticised over the past 60 years. Huber and others, for example, proposed “changing the emphasis towards the ability to adapt and self- manage in the face of social, physical and emotional challenges” (Huber et.al.). Notions as to what being healthy means varies widely, being shaped by our experiences, knowledge, values and society’s expectations. As conditions in society changes, what is considered to be healthy and “normal” also changes to reflect care practice, medical advances and individual needs and desires.
The capacity to select relevant health promotion theories or models, and apply them in practice is a key competence for public health, particularly as the focus of health and social care practices has shifted towards a more proactive approach to well-being.
Models of health are theoretical concepts of health. The biomedical model of health focuses on the physical or biological aspects of disease and illness and is associated with diagnosis, cure and treatment. The emphasis is on attempting to return the individual to a pre-illness state, irrespective of their lifestyle/living conditions, thus excluding psychological, environmental and social influences. It is an interventionist approach with the aim of providing freedom from medically defined disease and disability. The advantages of this approach are that it creates advances in technology and research, preserves life and can return someone back to good health. However, this model can be dependent on the availability and costs of effective screening and treatment. This approach also has a narrow view of health and doesn’t promote good health or encourage healthy lifestyles, concentrating on the condition rather than the cause.
The social model of health attempts to address the broader influences on health (social, cultural, environmental and economic factors) rather than disease or injury and encourage adoption of a healthier lifestyle. It is a community approach, focusing on policies, strategies, education and health promotion. This model goes beyond lifestyle and behaviour changes and accepts the need for social change as prerequisites for health. However, critics such as Ewles and Simnett (1999) suggest that educated middle and upper class social groups are more likely to respond more readily to these health messages.
There are several behaviour change models that are of importance for effective health promotion. The health belief model (Rosenstock et.al), suggests that an individual is most likely to undertake the recommended preventative health action if individuals perceive a threat to their wellbeing and that the benefits of engaging in behaviour change outweigh the costs associated with that behaviour.
The theory of reasoned action (Ajzen et.al.) focuses on people’s intentions to change and the influence of “significant others” such as family, friends and peers. Social learning theory (Bandura et.al.) is grounded in the belief that human behaviour is determined by interaction between cognitive (knowledge and attitudes), behavioural (skills and practices) and environmental (community services, attitudes of peers) factors.
The stages of change model (Prochaska et.al.) identifies five stages of behaviour: pre-contemplation, contemplation, preparation, action and maintenance. It can be used to tailor interventions to the stage the individual has reached in the change process. This model is widely used with individuals with issues related to addiction (drugs, alcohol or smoking) or obesity.
For most health promotion interventions, the relationship between input and outcomes is complex. The use of theory helps to unpick the complexity. Pawson and Tilley (2004) argue that these models do not work directly in themselves, but bring resources that allow people to generate change.
Designing, implementing and evaluating a health promotion campaign
Traditionally, health promotion had an element of being mandatory, with the accent on fear such as in the 1853 Vaccinations Act, whereas modern health promotion is about “shaping and reinforcement of healthy behaviour” (Soames Job 1988 p167).
There are many ways in which health and social care workers can communicate health promotion messages to the community and campaigns are more likely to be successful where a multi-level approach is used, using different strategies for particular individuals or groups. The United Kingdom has a strong tradition of public health practice and education. This needs reinforcing, as care services
strive to achieve health educational excellence despite rapid changes, rising expectations, and reduced resources.
In ill-health prevention, there are three strategies in reducing prevalence of disease: primary prevention (for example through vaccination, seeking to eliminate risks of getting a disease), secondary prevention (through early treatment, to prevent the transmission of pathogens to susceptible hosts or educating the population about signs of illness that require prompt referral to health care), and tertiary prevention (to soften the impact of an ongoing illness or injury that has lasting effects, by helping people to manage long-term, often complex health problems in order to improve their quality of life and life expectancy). Public health promotion is therefore concerned with making a diagnosis of a population’s health problems, establishing the causes and effects of those problems, and determining effective interventions.
Effective health promotion campaigns must begin with clear aims and objectives, which must be “SMART”: specific, measurable, achievable, relevant and within a specific time frame. To begin, the campaign needs to identify its target audience (e.g. care professionals, community groups, general public), present a key message and from then a course of action and desired outcome can be proposed. Once these proposals have been established, consideration can then be given as to how the health campaign can be communicated and distributed for maximum benefit.
Health communication is generally based on systematic planning models drawn from health promotion and public health practice. The most commonly used are Precede-Proceed (Green and Kreuter 2005) and Intervention Mapping (Bartholemew et al. 2006). The former starts with the desired outcome and then works backwards systematically to complete a campaign plan, whilst the latter proposes a path to follow from the identification of a problem to the proposal of a solution.
There are many ways in which health promotion can be communicated, including individual face- to-face interaction, although the effectiveness of this is hard to quantify. However, generally speaking, health and social care practitioners are held in high esteem within society. Health campaigns often utilise these professionals to plan specific events linked with national campaigns, sometimes with the help of celebrities (for example in the “Look to the Stars” celebrity health campaigns).
Campaign slogans can be effective to grab the public’s attention. Perhaps the most successful in the UK was the “AIDS: Don’t Die of Ignorance” campaign of 1986. Posters can also be effective for catching the attention of the target audience, whilst leaflets are the backbone of health education, providing these are available in easy read format for those who lack literacy skills.
Mass media, including social media are the most effective means of reaching large population and raising public awareness (e.g. “Stoptober”, Cancer Awareness Month etc). However, there are often conflicting stories circulated via the mass media which can undermine an effective campaign, such as the now-discredited link between the MMR vaccine and autism widely reported in the UK in 1988.
Prior to launching the campaign, there should be a specific launch date decided where there could be a news release and a list of contacts and experts available for media interviews, liaising with other agencies to ensure they are able to provide support and fit in with the proposed timescale. Once planning agreed, milestones can be established to ensure enough people are recruited to effectively participate in the campaign. These milestones can contribute to both implementing and evaluating a health promotion campaign through continuous targeted achievements.
Health campaigns by their very nature are public and therefore open to scrutiny and may be evaluated both internally and externally. Evaluation may be a final summative assessment at the end of the campaign to establish whether the initial aims and objectives have been met (this is termed an outcome evaluation) or by ongoing formative feedback (an evaluation of process). The effectiveness of any evaluation is very much reliant on how specific the initial aims and objectives were and what criteria needs to be met to reach the desired outcome. It is not always possible to accurately predict the final outcome in advance, because of the unpredictability of human behaviour or unintended or unexpected by-products such as better community relations or adverse publicity.
It is sometimes hard to measure the precise outcome of a campaign within the specified time frame, particularly with regard to behaviour change. For example, whilst at any one time most smokers would like to quit, many outside factors can influence a person’s level of motivation such as stress or peer pressure. However, the health campaign may have “sowed the seeds” in terms of changing attitudes, even if not immediately apparent.
In a world of limited resources, there can be cost implications attached to how effective a health campaign is deemed to be. For example how can it be proven categorically that a no smoking clinic for one small group of individuals is considerably less expensive than extensive lung cancer treatment. It may be several years before health promotion succeeds in changing disease patterns. For example, whilst there may be reductions in the numbers of people smoking following a health campaign, many of those who have quit may already have undiagnosed cancer or heart or lung disease; therefore it may take time for reducing smoking levels to take effect. In addition, there may be short term increased expenditure where there is increased take up of cancer screening, even though this may be a financial as well as healthy investment in the longer term.
References
Ajzen, I et.al (1992). “A Comparison of the Theory of Planned Behavior and the Theory of Reasoned Action” in Personality and Social Psychology Bulletin, February 1992 vol. 18 no. 1 3–9, Los Angeles, Sage
Bandura, A. (1963): Social learning and personality development, New York: Holt, Rinehart, and Winston
Downie R., Tannahill C, Tannahill A. (1996): Health Promotion: Models and Values, Oxford, Oxford Medical Publications
Ewles L. & Simnett, I. (1999): Promoting Health: A Practical Guide, 4th edition, Edinburgh, Bailliere Tindall|access-date= requires |url= (help)
Huber, M. (et.al.) (2011): “How should we define health?” (in BMJ 15 June 2011), London, BMJ
Pawson, R. and Tilley, N. (2004): Realistic Evaluation, London, Sage
Prochaska, J. O. (et.al) (1994): Changing for good: the revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits, New York: W. Morrow
Rosenstock, I. (1974). : “Historical Origins of the Health Belief Model” in Health Education Behavior 2 (4): 328–335, Los Angeles, Sage
Soames Job, R.F. (1988): “Effective and Ineffective Use of Fear in Health Promotion Campaigns” in American Journal of Public Health, February 1988, Vol. 78, №2, Washington DC, American Public Health Association
Tannahill, A. (1985): “What is health promotion” in Health Education Journal 44 (4) pp167–168, London, Sage
Tannahill, A. (2009) : “Health promotion: the Tannahill model revisited” in Public Health Journal Volume 123 issue 5 pp 396–399, London, Elsevier
World Health Organization (1948): Official Records of the World Health Organization, no.2, p.100), New York, WHO
