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Approaches to Health Promotion
Puja Myles
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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
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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
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The context of health promotion: individual vs. population
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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
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Ethical and philosophical principles underpinning health promotion practice
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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
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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.
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Approaches to Health Promotion
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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
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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
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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
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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.
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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
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Settings WHO 1998 definition:
“…identified as having physical boundaries, a range of people with defined roles and an organisational structure …”
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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
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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
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2 useful additions to your Health Promotion toolkit
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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
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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)
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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
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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
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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:
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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?
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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?
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