1. Approaches to Health Promotion
Puja Myles

2. Learning Outcomes
To recognise the ethical and philosophical principles underpinning health promotion practice
To categorise and describe various approaches to health promotion
To choose an appropriate health promotion approach in different contexts

3. Session Outline
The context of health promotion: individuals vs. population
Intervention ladder and ethical underpinnings
Approaches to health promotion
Social Marketing and Media Advocacy
Group exercise

4. The context of health promotion: individual vs. population

5. Sick individual and sick populations (Rose)
Populations as a whole may be susceptible to a particular disease
Not all individuals belonging to a susceptible population get that disease
Determinants of illness (or health) are different depending on the level: individual or population
Should health promotion practice focus on individual determinants of health or population determinants?
Medical approaches to health promotion will tend to focus on individual determinants of health

6. Ethical and philosophical principles underpinning health promotion practice

7. Why should you concern yourselves with ethics and philosophy?
Does the choice of health promotion model and approach by an individual, organisation or government reflect particular individual and societal values?
David Seedhouse: “Every health promotion activity has an underlying political ideology”
All health promotion- even the most routine and mundane- is based on one political philosophy or another

8. Why is state intervention required?
Tension between autonomy and state paternalism
Does the state have a duty to protect its citizens and if yes, under what conditions?
The concept of ‘public goods’
Beneficence
Non-maleficence
Respect for autonomy
Justice
Equity, equality
Public goods- non-rival, non-excludable
Is health a public good? Not all aspects; largely a private good; some elements like herd immunity or provision of clean water and environment, security are public goods.

9. Approaches to Health Promotion

10. 3 main approaches Behavioural approaches Self-empowerment approaches
Collective action or community development approaches
These are not mutually exclusive!!
Naidoo and Wills (2000) also include medical (or preventive), educational and social change (linked to behaviour change) approaches

11. Other ways of approaching Health Promotion
Targeted versus universal approaches
Settings approach
Ecological or whole-systems approach
Related concepts: Prevention Paradox (Geoffrey Rose)
Hancock’s ecological model of health; Dahlgren and Whitehead’s Layer of Influence model

12. Targeted vs. Universal approaches
Targeted (high-risk) approach: Identify individual person or group of people at high risk, offer advice & treatment
Universal (population) approach: Lower the average level of risk in the population

13. Prevention Paradox
A large number of people exposed to a small risk may generate many more cases than a small number exposed to high risk.
A preventive measure that brings large benefits to the community offers little to each participating individual. 

14. Settings From Ottawa Charter:
“Health is created & lived by people within the settings of their everyday life: where they learn, work, play and love”.
Schools
Workplaces
Homes
Communities
Cities

15. Settings WHO 1998 definition:
“…identified as having physical boundaries, a range of people with defined roles and an organisational structure …”

16. Settings Settings approach Enables access to groups or individuals
Focus: whole ethos of the setting is health promoting (holistic approach)
Integration of health promotion into the daily activities of the setting
Example: ‘health promoting schools’ rather than ‘health promotion in schools’
Creation of conditions for reaching out into the community

17. Settings Who is left out? Possible solutions:
Constrained to those within setting?
Possible solutions:
Go for novel settings
Demands organisational change & commitment
Balance between top-down and bottom-up approaches
The concept of ‘hard-to-reach’ populations

18. 2 useful additions to your Health Promotion toolkit

19. Social Marketing Included in behaviour change approaches
The adaptation of commercial marketing techniques to achieve specific behavioural goals for a social good.
“A social change campaign is an organized effort conducted by one group (the change agent) which attempts to persuade others (the target adopters) to accept, modify, or abandon certain ideas, attitudes, practices or behaviour.” Kotler, Roberto, & Lee, 2002
Consumer-oriented approach, but…
Contrast with commercial marketing: profit goal

20. Media Advocacy-1
Not a health promotion approach per se but a means of getting an issue on the policy agenda
Kingdon’s policy model:
Windows of opportunity when coupling of three streams occurs: problems, policy (technically feasible and sustainable solutions) and politics (commitment)

21. Media Advocacy-2
Media advocacy by ‘policy entrepreneurs (like you!!) could result in the recognition of an issue as a problem, create awareness of possible solutions and generate wide scale political commitment

22. Further reading-1
1. Nuffield Council on Bioethics (2007). Public Health: Ethical Issues
2. Oxford Handbook of Public Health Practice 2nd ed. (2006):
Chapter 1.7 (Pp ): Understanding ethics in Public Health (Angus Dawson)
Chapter 4.7 (Pp ): Influencing governments via media advocacy (Simaon Chapman)
Chapter 3.7 (Pp ): The public health response to ‘hard to reach’ populations

23. Further reading-2 3. Social Marketing- Big pocket guide (2007)
4. Rose, G. (2001). Reiteration: Sick Individuals and sick populations. International Journal of Epidemiology; 30:

24. Scenario 1:HIV/AIDS
Targeted (high-risk) or Universal (population) approach?
Behavioural/Self-empowerment/Community Development approach?
What are the values and assumptions underlying your choices?

25. Scenario 2: Obesity
Does the state or its agents (NHS/Public Health?!) have a duty to intervene?
Look at the intervention ladder- which rungs would you choose?
What approaches would you use: behavioural/self-empowerment/community development?
What values and assumptions underpin your choices?