Health Promotion Theoretical Frameworks Jennie Naidoo and Nick de Viggiani June 2009

Why theory? Health promotion is a practical enterprise, we should just get on and do it. Professionals are well equipped to promote people’s health. Theory is important because it makes explicit our aims and our choice of strategies. Theory is necessary to achieve transparency and accountability. Theory helps to ensure we select the most effective and acceptable strategies and ways of working. Theory helps demarcate health promotion practice.

The role of theory Theory is the representation of reality in a way that seeks to make explicit underlying factors, connections and outcomes Theory helps us explore reality and identify changes we might seek to make Theory identifies the range of possible interventions and their ramifications, as well as factors that might impede progress

Definition of theory “systematically organized knowledge applicable in a relatively wide variety of circumstances devised to analyze, predict or otherwise explain the nature or behaviour of a specified set of phenomena that could be used as the basis of action” (Van Ryn and Heaney, 1992)

Health promotion theories There are many different theories that guide health promotion interventions Most theories are based in the social sciences including sociology, education, psychology and policy studies Different approaches to health promotion tap into different theoretical perspectives and academic disciplines

5 different approaches to health promotion Medical Behaviour change Educational Empowerment Social change

Medical Relies on a medical view of health and professional interventions based on medical science e.g. immunisation Includes primary, secondary and tertiary prevention

Behaviour change The aim is to encourage individuals to adopt healthy behaviours There are many different models of how to achieve behavioural change, including factors such as media coverage, the example of role models, information, and supportive environments This is a popular approach because it is focussed on individuals and retains a role for the professional who gives information and advice

Theory of Planned Behaviour (Ajzen 1991)

Education The aim is to provide information to enable people to make informed choices re. their health learning involves 3 aspects: Cognitive (information and understanding) Affective (attitudes and feelings) Behavioural (skills)

Empowerment Enables people to gain control over their lives Seen as ethically sound because it supports autonomy and free choice Can be individually or community focussed

Social change The focus is to change the socio-economic environment to enable people to make healthier choices and adopt healthier behaviours – to make the healthy choice the easier choice This is a top-down approach including policy change, media advocacy and legislation

Stages of change model (Prochaska and DiClemente 1984, 1986) A cyclical process with the following stages: Precontemplation Contemplation Ready to change Making a change Maintaining the change Relapse

Health Promotion Theoretical Models There are many health promotion models and theoretical frameworks that seek to explain and explore how health can be promoted. We will examine 3 contrasting models: Beattie 1991, Green and Kreuter 2005, and Dahlgren and Whitehead 1991

Beattie 1991, 1993 Beattie’s model uses 4 paradigms generated from the dimensions of mode of intervention (authoritative, negotiated, bottom up – vertical axis) and focus of intervention (individual to collective – horizontal axis). The resulting 4 paradigms correlate to different political perspectives.

Green and Kreuter (2005) : Precede-Proceed Model This planning model focuses on the identification of predisposing, reinforcing and enabling factors in order to diagnose an appropriate response (media advocacy, policy, organisational change, health education)

PRECEDE-PROCEED Framework Phase 5 Administrative Policy Assessment Phase 4 Educational & Ecological Assessment Phase 3 Behavioral & Environmental Assessment Phase 2 Epidemiologic Assessment Phase 1 Social Assessment Predisposing factors Health services Behavior & lifestyle Health Education Health Promotion Policy, Regulation Reinforcing factors Quality of life Health Environment Enabling factors Phase 7 Process Evaluation Phase 8 Impact Evaluation Phase 9 Outcome Evaluation Phase 6 Implementation

Dahlgren and Whitehead 1991 This model identifies the determinants of health ranging, from the individual to the societal to the global. It is often used to flag up issues re. inequalities in health as it makes clear the constraints on individuals arising from social, cultural, economic and environmental factors. This model also identifies the need for structural interventions to impact on the causes of health and illhealth

References Beattie, A (1991) ‘Knowledge and control in health promotion: A test case for social policy and social theory’ in Gabe, J Calnan, M Bury, M (Eds) The sociology of the health service London, Routledge Dahlgren, G and Whitehead, M (1991) Policies and strategies to promote social equity in health Stockholm, Institute of Futures Studies Green, LW and Kreuter, MW (2005) Health promotion Planning: An educational and ecological approach 4th edn. New York, McGraw Hill Naidoo, J and Wills, J (2000) Health Promotion: Foundations for Practice 2nd Edn London Bailliere Tindall NB 3rd Edn. In press, due 2009

References con’t Prochaska, JO and DiClemente, C (1986) ‘Towards a comprehensive model of change’ in Miller, WR and Heather, N (Eds) Treating addictive behaviours: Processes of change New York, Plenum Van Ryn, M and Heaney, CA (1992) ‘What’s the use of theory?’ Health Education and Behaviour Vol. 19 No. 3: 315-330 Wills, J (2007) ‘Theoretical perspectives on promoting public health’ in Earle, S Lloyd, CE Sidell, M and Spurr, S Theory and Research in Promoting Public Health London, Sage Open University