Health Promotion PDF

Health promotion Prof. dr. Benedicte Deforche 1. Introduction 1.1. Levels of prevention within public health based on prevention measure 1.2. Levels of prevention within public health based on stages of disease 2. Health promotion 2.1. Health...

Health promotion Prof. dr. Benedicte Deforche 1. Introduction 1.1. Levels of prevention within public health based on prevention measure 1.2. Levels of prevention within public health based on stages of disease 2. Health promotion 2.1. Health education versus health promotion 2.2. The origins of health promotion 2.3. Approaches to health promotion 2.3.1. The medical approach 2.3.2. The educational approach 2.3.3. The empowerment approach 2.3.4. The social change approach 3. Health-promoting healthcare organizations 4. Ethical aspects of health promotion 5. Conclusions 1. Introduction Public health aims to improve health and quality of life among whole populations through different prevention strategies. Different types of prevention can be distinguished, based on type of prevention measure that is applied or based on stage of disease of the targeted population. Being able to distinguish these different types of prevention and using common terminology facilitates communication between public health professionals. 1.1. Levels of prevention within public health based on prevention measure Based on the applied type of prevention measure, a distinction is made between health protection, disease prevention and health promotion. Health protection includes measures taken without the direct involvement of citizens to prevent harm to health, often in the form of regulations (e.g., food quality and safety regulations, water purification, occupational safety standards, soil testing of farmland). Health protection is generally the responsibility of public health departments or government agencies. Disease prevention covers “measures to reduce the occurrence of risk factors, prevent the occurrence of disease, to arrest its progress and reduce its consequences once established” (Nutbeam and Muscat 2021). A typical example of disease prevention is vaccination (e.g., polio or COVID-19 vaccination). Disease prevention always starts from a threat to health in the form of a risk factor or a disease and tries to protect as many people as possible within a population. Health promotion starts from a healthy population and focuses on increasing the capacity of individuals to improve their own health and on designing a physical, socio-cultural, economic, and political environment that promotes healthy choices. Health promotion is defined as “the process of enabling people to increase control over, and improve their health” (Nutbeam and Muscat 2021). Health promotion measures to discourage smoking, for example, might include education about health risks, ban on smoking in public places and restaurants or taxes on tobacco. In practice, there is overlap between disease prevention and health promotion. The promotion of positive health also reduces the risk of disease and vice versa. Disease prevention is mainly practiced in the healthcare sector, while health promotion is also practiced in other sectors. 1.2. Levels of prevention within public health based on stages of disease Based on stages of disease, four different types of prevention can be distinguished: primary prevention, secondary prevention, tertiary prevention, and quaternary prevention (see Figure 1). Primary prevention aims to prevent diseases or to remove causes of diseases before they occur (Nutbeam and Muscat 2021). Primary prevention, therefore, targets a healthy population. Primary prevention strategies can only be undertaken when the causal factors of disease have been identified and when they are modifiable. Strategies may target specific groups (e.g., promoting influenza vaccination in the elderly or breastfeeding among young mothers) or may be directed to the whole population (e.g., stimulating washing hands to prevent spread of infectious diseases or providing cycle paths to promote active transport). Secondary prevention refers to the early detection of the disease so that it can be treated at an early stage, thus increasing the chance of cure and reducing the risk of long-term adverse effects or further spread of the disease. Secondary prevention targets healthy-appearing individuals with subclinical forms of disease (i.e., no overt symptoms) (Nutbeam and Muscat 2021). This type of prevention is only useful when there is a valid test to detect a disease at an early stage and when the disease can be treated effectively at an early stage. Secondary prevention strategies include population-based screening programs for early detection of diseases, such as breast cancer in women or metabolic diseases in newborns. Strategies may target all individuals within a certain subgroup (e.g., all women aged 50-69 years) which is called universal screening, or may target risk groups (e.g., women with a family history of breast cancer) which is called case finding. Tertiary prevention aims to reduce the severity and chronic effects of a disease (Nutbeam and Muscat 2021). Tertiary prevention targets symptomatic patients. It does not prevent the onset of disease, but seeks to prevent complications or functional impairment caused by disease and to increase quality of life. Examples are the promotion of a healthy diet and physical activity in type 2 diabetes patients to prevent cardiovascular disease, rehabilitation programs in cardiac patients, self-management of asthma, and pain management in palliative care patients. Quaternary prevention has been defined as “an action taken to protect individuals (persons/patients) from medical interventions that are likely to cause more harm than good” (Martins et al. 2018). Quaternary prevention targets patients as well as healthcare providers as they suggest medical interventions to their patients. It aims to avoid superfluous examinations, false positives and unnecessary anxiety in the patient by taking into account scientific evidence and ethical considerations. Quaternary prevention can be applied to primary prevention (e.g., avoiding unnecessary vaccinations), secondary prevention (e.g., avoiding overscreening of cancer) as well as tertiary prevention strategies (e.g., avoiding overtreating hyperglycemia) (see Figure 1). Quaternary prevention also refers to patients who feel ill, but do not have a disease. These patients might have medically unexplained symptoms and are also at risk for overtreatment and harm. Figure 1: Different types of prevention based on stage of disease (based on Martins et al. 2018) Within mental health promotion, a different classification of prevention is used based on the stages of disease: universal, selective, indicated and care-related prevention (National Research Council and Institute of Medicine 2009). Universal prevention actively promotes and protects the mental health of the healthy population (e.g., school-based programs targeting bullying). Selective prevention tries to prevent people with one or more risk factors for a certain mental disease from getting ill (e.g., programs offered to children who have been exposed to bullying to prevent adverse mental and emotional outcomes). Indicated prevention tries to prevent initial symptoms from worsening into a mental disease (e.g., interventions for children with elevated symptoms of anxiety). The aim of care-related prevention is to prevent that an existing mental disease leads to complications, limitations, a lower quality of life or death (e.g., interventions for adolescents diagnosed with anorexia to prevent further mental health issues). 2. Health promotion 2.1. Health education versus health promotion Incorrectly, the terms health education and health promotion are sometimes used interchangeably. Health education has been defined as “any combination of learning experiences designed to help individuals and communities improve their health by increasing knowledge, influencing motivation and improving health literacy” (Nutbeam and Muscat 2021). An important concept within that definition is health literacy, representing “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (Nutbeam 1998). Examples of health education interventions are educational programs at school to promote safe sex, invitation letters to encourage women to participate in breast cancer screening or cooking classes for young adults in the community to promote healthy eating. Health education focuses on changing health behavior of individuals and communities and is an important component of health promotion. Health promotion moves beyond a focus on individual behavior towards a wide range of environmental interventions. Health promotion includes any planned combination of educational, political, regulatory, and organizational support for actions and conditions of living conducive to the health of individuals, groups, and communities (Green et al. 2005). Hence, health promotion goes beyond health education by adding social changes (e.g., support to be physically active by sport partner), physical environmental changes (e.g., availability of street sewage, free water at school or standing desks at work) and/or policy changes (e.g., no smoking in public areas, transport policies favoring active transport or obligation to wear a seat belt in the car). The basic principles of health promotion are: - Holistic: Health promotion takes a bio-psycho-social perspective, paying attention to the person in his or her biological, psychological, social, economic and societal context. Health promotion aims to promote physical, social and mental health. - Participatory: Health promotion is based on the active involvement of the population. Health promoters do not provide services to the population, but work together with the population. Health promotion is not only a matter of professionals but of society as a whole. - Emancipatory: Health promotion aims at empowering people to take control over their own health and to organize their environment and their community in such a way that it benefits their health. - Equity: Tackling health inequalities and creating equal health opportunities for all are key targets in health promotion. - Sustainable: Health promotion aims to bring about changes that individuals and communities can sustain after the initial funding or initiative has ended. - Multidisciplinary: Health promotion uses insights from different scientific disciplines, such as psychology, sociology, epidemiology, biomedical sciences, communication sciences, economics and political sciences. Professionals from different disciplines need to work together and join forces to create healthy lifestyles and environments. - Multi-strategy: Health promotion uses a combination of methods and strategies including policy developments, organizational change, community development, legislation, fiscal measures, taxation, advocacy, education and communication. 2.2. The origins of health promotion Although health promotion was not defined as a discipline until the second half of the 20th century, basic concepts of health promotion were already applied far back in history. In ancient times, the Egyptians fought rats to avoid plagues, used mosquito nets and recognized the importance of moderate alcohol consumption. The ancient Greeks were the first to recognize that health and disease are influenced by physical and social environments as well as by human behavior. In the Roman Empire, the state, not the individual, was believed to have the greatest impact on health. Aqueducts were built to transport clean water and public baths and public sanitation were promoted. In the Middle Ages, quarantines were used during pandemics. In the 19th century, better housing, construction of sanitation and better availability of food contributed to the prevention of health problems in overpopulated cities. Important preventive achievements in the early 20th century were the development of vaccinations and hygiene measures against the spread of infectious diseases. In the second half of the 20th century, breakthroughs in curative medicine and its possibilities to cure diseases led to a decreased attention to prevention. However, in that period, there was also an increase in non- communicable diseases (e.g., cardiovascular diseases, cancer, type 2 diabetes, addiction, mental problems), HIV and hepatitis C caused by unhealthy behavior. Despite a well- developed curative healthcare system and a well-functioning system for traditional disease prevention, these chronic diseases could not be cured. This called for new strategies and led to a renewed focus on prevention. The basis of modern health promotion is the report published in 1974 by Marc Lalonde, Canada's Minister of Health at that time, who introduced the Health Field Concept (Lalonde 1974). In those days, health policies were focused on health insurance for medical care. The Health Field Concept brought a new perspective on health by suggesting that health is not only determined by healthcare systems, but also by human biology, the environment, and health behaviors. Increasing research (among others the US Surgeon General’s Report on Smoking in 1964) showed that the prevalence of chronic diseases (e.g., cardiovascular diseases and cancer) was linked to lifestyle habits and that substituting high-risk behaviors (e.g., tobacco use, high alcohol use, poor diet, physical inactivity) by healthy behaviors could prevent the development of these diseases (Breslow et al. 1999). The Lalonde report caused a shift from disease treatment to health promotion and led to a series of initiatives driven by the World Health Organization (WHO), including the Alma Ata Declaration in 1978 in which the ‘Health for All by the year 2000’ goals were presented. The Alma Ata Declaration shifted the focus of health systems from primary medical care to primary healthcare, which focuses on all services that affect health (including, for example, education and housing). Although the Lalonde Report made policymakers aware of the broad influences on health, it led to the implementation of health education campaigns that mainly aimed at changing individual behaviors. This individualistic discourse was criticized as victim-blaming, as health education puts too much emphasis on individual responsibility, while ignoring individual limitations due to economic and material constraints. The first International Conference on Health Promotion organized by the WHO in Ottawa (Canada) in 1986 was stimulated by the Lalonde Report and was built on the progress made through the Alma Ata Declaration. The Ottawa Charter for Health Promotion (WHO 1986) was released at this conference. This charter formally defined health promotion and caused a paradigm shift in public health. It has set the strategic course for more than 30 years and is still influential today. The Ottawa charter identified for the first time the prerequisites for health including peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity, which cannot be guaranteed by the health sector alone. The charter defines health promotion (see Section 1.1) and describes both the basic strategies for health promotion and the basic fields of action in health promotion to achieve the goal of ‘Health For All by the year 2000’ (see Figure 2). The basic strategies for health promotion are advocate, enable and mediate. Advocating strategies create conditions for health. Enabling strategies ensure health equity by providing a healthy environment and access to information for everyone and by teaching skills to make healthy choices. Mediating strategies include collaboration between all sectors to promote health. The five basic action areas for health promotion are: - Develop personal skills: Increasing knowledge about the factors that determine health, and ensuring that people have the personal skills and are motivated to make healthy choices. - Create supportive environments: Creating physical, socio-cultural, economic and political environments that support health. Generating living, working and school environments that are safe, stimulating, enjoyable and where the healthy choice is the obvious choice (e.g., safe cycle paths, healthy meals at school). - Strengthen community action: Empowering existing networks within the community (e.g., youth work, neighborhood work, etc.) to participate in and have control over local health promotion actions by mobilizing human and material resources within the community. - Build healthy public policy: Policy makers in all sectors and at all levels should be aware of the impact of their decisions on health and accept their responsibilities for health. The healthy choice must be made the easiest choice by policymakers. - Reorient health services: From curation to prevention and health promotion. Health professionals need to learn new skills and collaborate with other disciplines and sectors. Health services should be accessible to all, especially to the most vulnerable. Figure 2: Ottawa Charter for Health Promotion (Savičiūtė et al., 2012: available via license: Creative Commons Attribution 4.0 International) ‘Building healthy public policy’ as a key action area for health promotion led to increased attention to the role of non-health sectors in promoting health and was the focus of the second International Conference on Health Promotion in Adelaide (Australia) in 1988. Finland, having a long tradition of promoting healthy public policy, introduced the term ‘health in all policies’ (HiAP) during its presidency of the European Union in 2006. HiAP is “an approach to public policy development across sectors, which systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity” (Nutbeam and Muscat 2021). Based on the Ottawa Charter, the International Union for Health Promotion and Education (IUHPE) developed the Core Competencies and Professional Standards for Health Promotion (CompHP) (Barry et al. 2012) to ensure that professionals practicing health promotion are equipped with the required competencies to implement current evidence in practice. The CompHP describes which ethical values and knowledge about health promotion and disease prevention health promoters require and distinguishes the following nine competency domains: enable change, advocate for health, mediate through partnership, communication, leadership, assessment, planning, implementation, and evaluation and research. 2.3. Approaches to health promotion Different approaches to health promotion can be distinguished: 1) medical approach, 2) educational approach, 3) empowerment approach and 4) social change approach (Wills 2023a). These approaches are combinations of the following orientations: individual-oriented versus environment-oriented, health-oriented versus disease-oriented, using healthcare services versus using other settings. They reflect different ways of working, focus on different action areas of the Ottawa Charter and have different objectives and methods. Each approach has its own advantages and disadvantages. 2.3.1. The medical approach The medical approach focuses on the prevention of medically defined diseases which is related to the concept of disease prevention (described in Section 1.1.). This approach includes medical interventions to prevent disease (e.g., screening or vaccination programs), based on sound medical and epidemiological evidence. This is an individual-centered approach that does not take into account physical, socio-cultural, economic and political environmental factors influencing health. Medical and health professionals are seen as experts who know what is best for the patient or the population, leading to expert-led, top-down interventions expecting people to comply with recommendations. Educational and persuasive techniques are used, often warning, which can make actions appear paternalistic (e.g., persuading the population to get a COVID-19 vaccination). This approach to health promotion is mainly applied within the healthcare sector and by medically oriented organizations. 2.3.2. The educational approach The aim of the educational approach is to increase knowledge and skills about healthy lifestyles. This approach is also individual-centered. Diseases are caused by individual behavioral factors and are therefore avoided or solved by individual action. An important difference to the behavioral change approach is that no persuasion techniques are used to motivate behavioral change in a healthy direction. With this approach, experts make sure that the individual can make an informed choice between healthy and unhealthy behavior. These experts (usually outside the medical sector) provide information about different values and beliefs, not about the one and only correct vision, and put themselves on an equal level with the individual. It is assumed that, based on this information, the individual can make a rational choice. This approach mainly reaches the higher educated and may increase health inequalities. It ignores the fact that many people, especially from the lower social classes, are not able to use the information provided to make an informed choice. 2.3.3. The empowerment approach The empowerment approach aims to enable individuals to determine their own health needs and make their own decisions and choices based on their interests and values. Empowerment can be defined as “a process through which people gain greater control over decisions and actions affecting their health” (Nutbeam and Muscat 2021). This approach is also individual- centered but uses a bottom-up method. The health professional does not take on the role of an expert, but of a facilitator who helps to identify individual needs and to acquire the necessary knowledge and skills to bring about change. Besides psychotherapeutic techniques, especially skills training is used. 2.3.4. The social change approach The social change approach focuses on changing the physical, socio-cultural, economic or political environment to make the healthy choice the easier choice and hence improve population health. This can often only be achieved by involving sectors other than the health sector, such as the economic and social sector, traffic, agriculture, etc. This is an environment- oriented top-down approach. Applied methods are advocacy towards policymakers, negotiating and policy planning to bring about the necessary environmental changes (e.g., legislative, organizational, or regulatory changes such as providing safe bike lanes, ban on tobacco advertising, or taxes on alcohol). 3. Health-promoting healthcare organizations Although traditional healthcare organizations focus on care and disease prevention, health- promoting healthcare organizations have broadened their focus from only treating diseases to also promoting health, and from a narrow concern with patients to also including family, healthcare providers and the wider community (Hancock 2012). Health-promoting healthcare organizations incorporate the aims of health promotion, develop a health-promoting organizational structure, culture and environment, provide active, participatory roles for patients and staff members and actively cooperate with the community. For health-promoting healthcare organizations as workplaces for staff members we refer to Section 5.4.3. The implementation of health promotion in healthcare organizations has led to many benefits for patients such as improved health outcomes and health behaviors, reduced hospital readmissions, lowered healthcare costs, and increased patient empowerment and satisfaction. Although health promotion interventions in the healthcare setting seem obvious, there are many challenges to realize these. Most patients are treated by a multidisciplinary team of healthcare professionals with varying degrees of training in health promotion. Health promotion is ideally implemented in the basic education of health professionals and is best supported by further training in the healthcare setting. Further, within a healthcare organization there might be divergent priorities of different clinicians and other professionals (prevention versus treatment). And finally, next to lack of training and support, lack of time is an important reason for not addressing health promotion in healthcare organizations. 4. Ethical aspects of health promotion Although promoting population health and preventing people from getting ill seems to be ethical, health promotion involves many ethical dilemmas (Wills 2023b). Is it ethical to encourage everyone to adopt a healthy lifestyle, even those who do not consider health important and prefer other values over health? Unlike curative care, health promotion is not demand-driven. Few smokers have asked for a smoking ban in public places. There are also few children who are happy about a ban on soft drinks at school. Some people find health promotion too nanny-state and government interference restricting their freedom and rights. Looking at the approaches to health promotion discussed in Section 2.3. from an ethical point of view, some of them may raise ethical questions. During the COVID-19 pandemic, residents of nursing homes in certain countries were no longer allowed to have visitors to protect the older adults from COVID-19. But some nursing home residents considered it more important to be able to see people and were happy to accept the risk of infection. A medical approach to health promotion was applied here, focusing only on physical health and not on mental and social health. Such approaches to health promotion are often perceived as paternalistic because the autonomy of citizens is not respected. Although the educational approach to health promotion respects autonomy by allowing people to make informed choices, we know that this approach is predominantly effective in the higher educated, which also raises ethical questions. In addition to widening health inequalities, the educational approach to health promotion can also generate feelings of fear, guilt, shame or frustration if people are unable to change their behavior. Social and economic conditions can limit individual health choices. Other individual-centered approaches such as the behavior change approach may be victim- blaming as they hold people entirely responsible for their own health (behaviors) and do not take into account that individuals may have limited influence on social and environmental factors that shape their behavior. Such health promotion strategies may stigmatize certain groups in society such as overweight people. Although environment-oriented approaches are generally considered more inclusive, some environmental strategies are also criticized as being paternalistic, such as nudging (i.e., choice architecture that alters people’s behavior in a predictable way without forbidding any options, for example, making healthy choices more attractive or even the default choice) and taxation of unhealthy products (e.g., tobacco, alcohol). There are four widely accepted bio-ethical principles used in the practice of health promotion (Beauchamp and Childress 2019). The first principle is respect for autonomy (i.e., ability to make own choices). Although autonomy is an important value in health promotion, there are restrictions on individual autonomy in the sense that personal choices should not harm the health of others (e.g., smoking in the car in presence of children). It is also justifiable to limit autonomy slightly if the harm that can be avoided is considerable, like, for example, making it compulsory to wear seatbelts in traffic. Health promotion allows rules that discourage, impede or prohibit unhealthy choices and/or the sale, advertising and accessibility of unhealthy products, but it is difficult to draw a line here. From when is the expected harm large enough and the restriction of autonomy not too strong? There is tension between the government's interest in intervening to protect the population from itself and the freedom of people to do ‘what they want’. In addition, there are often economic interests that outweigh health benefits. Next to autonomy, beneficence (i.e., doing good) and non-maleficence (i.e., avoiding harm) are widely accepted ethical principles. But what if a person does not want to follow the advice to adopt healthy behavior? The health promoter wants to do good and avoid bad, but this cannot be at the expense of autonomy, otherwise the health promoter's need to do good would be placed above the right to free choice. So, in some cases basic ethical principles conflict. Finally, justice (i.e., being fair and equitable) is an important ethical value. To be fair and equitable, more efforts should be made to improve the health of the most vulnerable people as they are currently bearing most of the burden of disease (see Section 6. Reducing inequalities in health). Ethical health promotion should aim to promote health by making the healthy choice the easiest choice, without widening health inequalities, and without stigmatizing or inducing guilt. It should be assured that health promotion interventions achieve positive health effects while avoiding damage to other things people value. As a health promotion professional, it is preferable not to cooperate with or be sponsored by partners who supply or produce products or services that have been shown to be harmful to health. To ensure ethical health promotion practice, most professional health promotion organizations use a code of practice like the framework for ethical health promotion in the UK (Society of Health Education and Health Promotion Specialists (SHEPS) 2009). 5. Conclusions This chapter provided an introduction to health promotion for public health professionals and researchers. Health promotion focuses on increasing the capacity of individuals to improve their own health and on designing a physical, socio-cultural, economic, and political environment that promotes healthy choices. This requires the collaboration and joint forces of professionals from different disciplines (e.g., education, work, urban planning, agriculture, social work). Health promotion is thus not only the responsibility of the health sector, as it requires collaboration of different sectors. Health promotion is important to cope with many of the challenges the world is facing today, such as climate change, food insecurity, health inequalities, population ageing, urbanization, non-communicable diseases, or new communicable diseases. Good health and well-being has been formulated as one of seventeen core Sustainable Development Goals (SDGs) to be achieved by 2030. Although health is just one goal for sustainable development towards a better future, health is inextricably linked to all other SDGs. For example, quality education and no poverty are important prerequisites for health, and vice versa, health contributes to successful education and poverty avoidance. Supporting the sixteen other SDGs is thus crucial to advance health promotion and at the same time, strategies that promote health are also key to achieve the other SDGs (Fortune et al. 2018). 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