Introduction to health promotion Dr John Hubley www.hubley.co.uk

With acknowledgements to Dennis Burkitt

World Health Report 2002 Simple, cost effective public health measures could lengthen the average human life span by five to 10 years The top 10 risk factors accounting for about 40% of the 56 million deaths in the world each year are underweight in children and mothers; unsafe sex; poor water, sanitation, and hygiene; indoor smoke from solid fuels; iron deficiency; high blood pressure; tobacco; alcohol; high cholesterol; and obesity. Two other factors are important in the developing world: zinc deficiency and vitamin A deficiency.

Health Field Model Human Biology (Genetics) Life style (Human Health behaviour) Health Services Environment

Primary Secondary Tertiary prevention prevention prevention healthy onset of advanced disabilty person symptoms symptoms death (reversible) (not reversible ) Primary Secondary Tertiary prevention prevention prevention screening rehabilitation case finding early prevention

Primary prevention Actions carried out with healthy people to maintain their health and prevent disease

Annual lung cancer death rates Death rates from lung cancer (per 1000) by number of cigarettes smoked, British doctors, 1951-61 Annual lung cancer death rates per 1000 Average number of cigarettes smoked per day

Secondary prevention Actions to promote early interventions when someone becomes ill to promote recovery and prevent the condition from becoming worse

A calendar from Cambodia promoting the DOTS approach to TB – essential to ensure adherance to prescribed doses To ensure effectiveness of treatment and the prevent the emergence of antibiotic resistance

Types of behaviours Decision-based behaviours – where a person goes through a conscious decision-making process before deciding to perform (or not to perform the behaviour) One-time behaviour – a behaviour that a person is expected to do only a few times in their life. (also usually a decision-based behaviour). Routine behaviour – something people do regularly - usually without a conscious decision (a behaviour might start as decision-based and then become a routine as it is integrated into their pattern of life) Addictive behaviour – when there is some physiological reinforcement of the behaviour through a biological adaptation in the person who becomes dependent on regular use of the substance.

How realistic is this message? Do people living in overcrowded housing have any choice? This is an example of victim blaming health education that puts all the emphasis on individual behaviour change and ignores social and economic influences on the individual

This photograph of a poster in a village in Cambodia promoting iodized salt for the prevention of goitre. One out every 4 –5 houses had stalls selling cigarettes – but iodized salt was not on sale. It is not enough to do health education – you have to make the health choice the easier one!

An effective response should Provide the information and power for the community to make decisions Make the healthy choice the easiest one Remove barriers to action

Ottawa Charter for Health Promotion Health Promotion - the process of enabling people to increase control over, and to improve, their health. Strengthen Community Action Develop Personal Skills Create Supportive Environments Enable Mediate Advocate Reorient Health Services Policy Build Public Healthy Source: Canadian Public Health Association - An International Conference on Health Promotion - November 17-21 1986 18

Promoting health Health Education Service Improvement Advocacy Communication directed at individuals, families and communities to influence: awareness/knowledge decision-making beliefs/attitudes empowerment individual and community action/behaviour change community participation Service Improvement improvements in quality and quantity of services: accessibility case management counselling patient education outreach social marketing Advocacy agenda setting and advocacy for healthy public policy policies for health income generation removal of obstacles discrimination inequalities gender barriers

HESIAD Exercise Take a health topic In groups identify suitable actions that might be taken for each component of HESIAD - health education, service improvement and advocacy

Components of an intervention Health Education directed at individuals, families and communities Service improvement improvements in quality and quantity of services: Advocacy agenda setting and advocacy for healthy public policy

Service Improvement Improvement in capacity of staff – training and support Development of new activities Reorienting existing activities to make them more effective/acceptable Strengthening communication/health education within services Improved patient education Outreach to schools, community, workplace Involvement of personnel in supporting community health promotion

Advocacy Influencing policy makers, leaders and media to raise profile of programmes Addressing legal, financial and service obstacles to health action

Equivalent terms Health education IEC (information, Education and Communication) Behaviour Change Communication Social marketing

Why is health education essential for promoting health? Community action to change surroundings - includes community participation in health decision-making. Adoption of healthy life style – e.g. diet, life style, child care, safety, stopping smoking, not taking drugs. Utilization of health services especially preventive services e.g. ante-natal care, immunization, family planning, screening. Recognition and prompt self referral on early symptoms eg for cancers, diabetes. Following (adhering to) prescribed medicines, completing doses. Support for health promoting policies e.g. seat belt wearing, traffic restrictions.

“any combination of learning opportunities designed to facilitate voluntary adaptation of behaviour which will improve or maintain health” Larry Green

"A process with intellectual, psychological and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal family and community well-being. This process, based on scientific principles, facilitates learning and behavioural change in both health personnel and consumers, including children and youth Helen Ross and Paul Mico

Levels for communication activities individual family wider family community district region national international Each level has factors which influence peoples’ actions Each level offers opportunities for different communication methods

Critical decisions in Public Health Education Actions to be promoted Target groups Messages Methods (settings, channels) Delivery – timing

Some common settings for public education school household Health facility Schools health facility community

Programme planning for health promotion Situation analysis Dialogue with stakeholders literature reviews Surveys to determine: Baseline situation Needs/Problems Influences on problem at different levels – community, service and policy/society level Opportunities/resources available to support intervention Plan health promotion Strategy: mix of advocacy, service improvement and health education Activities Targets/objectives Management Timing Costs Implement health promotion Monitor progress Evaluate impact Feedback from monitoring/evaluation