THIS ISSUE:
A
S
ENSIBLE
D
RINKING
P
ROGRAMME
U
SING
H
EALTH
P
ROMOTION
M
ODELS
By:
Kemi D. Dele-Ijagbulu (MBChB, PGDip, MPH)
[email protected]
www.kemidele.com
april 2014
Abstract
This article provides a brief introduction to the concept and definition of Health Promotion describing it as an evolving discipline and also demonstrates how health promotion models can be used in addressing contemporary issues such as the harmful effects of Alcohol. Beattie model is used to introduce a sensible drinking behavior.
1. THE MAIN FEATURES OF HEALTH PROMOTION 1.1.INTRODUCTION
Today’s concept of health promotion was adopted at the First International Conference on Health Promotion in Ottawa in 1986 which defined health promotion as the process of enabling people to increase control over and to improve their health. Health is redefined as a resource for everyday life rather the objective of living and as a positive concept emphasizing social and personal resources, as well as physical capacities. The Ottawa Charter recognized eight fundamental resources described as prerequisites for health, which are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Hence, health promotion is not just the responsibility of the health sector (WHO 1986: 1-4).
Health promotion is an umbrella term for a range of health-related activities. The concept focuses around five main action areas: build healthy public policy, create supportive environments, strengthen community actions, develop personal skills and re-orient health services. Its spectrum draws on the individualistic health education approach, health protection, disease prevention as well as the bigger picture that impacts people’s health, such as socioeconomic policies at local and national levels, preventive health services, community based work, organizational development, public policy and economic regulatory activities (Ewles & Simnett 1999: 25, 40). It widens up the traditional biochemical model of health to one that includes bio-psychological, socio-ecological and political economic models of health; addresses the determinants of health
and has a strong equity focus (Birn et al 2009: 133-134).
1.2.DEFINITIONS OF HEALTH PROMOTION
Many definitions of health promotion build on the themes of the Ottawa charter, differences being in broadening definition for health and in their emphasis. While the earlier definitions focus on health education and disease prevention, more recent descriptions reveals a shift in focus to issues like investment for health, the need for political advocacy, regulatory interventions, investment in strategies and infrastructure that addresses the determinants of health and building health promotion capacity and partnership, and as described by the Jakarta Declaration and the Bangkok Charter (Nutbeam 1998:351; Smith et al 2006: 340; WHO 2005).
"Health promotion is any combination of health education and related organizational, economic and political interventions designed to facilitate behavioural and environmental changes conducive to health." (Green 1979: 161)
Health Promotion is the provision of information and/or education to individuals, families, and communities that-encourage family unity, community commitment, and traditional spirituality that make positive contributions to their health status.
Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health.
American Journal of Health Promotion (1989) defined Health promotion as the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behaviour and create environments that support good health
practices. (O'Donnell 2009: iv)
"Health promotion is the process of helping people to take control over their lives so that they can choose options that are health giving rather than those that are health risky."
(Vetter et al, 1999: 216)
"Health promotion includes strengthening the skills of individuals to encourage healthy behaviours and it also includes building the healthy social and physical environments to support these behaviours." (Health Canada, 2005)
And finally, the WHO Bangkok chatter defined health promotion as the process of enabling people to increase control over their health and its determinants, and thereby improve their health. It is the core function of public health and contributes to the work of tackling communicable and non-communicable diseases and other threats to health. (WHO 2005)
1.3.HEALTH PROMOTION STRATEGIES
Health Promotion embraces holistic view of health and participatory approaches; focuses on the determinants of health – the social, behavioural, economic and environmental
conditions that are the root causes of health and illness; and uses multiple, complementary strategies to promote health at the individual and community level.
The Ottawa Charter identifies three basic strategies for health promotion. These are advocacy for health to gain support including political commitment to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health. These strategies are supported by five priority action areas as outlined in the Ottawa Charter for health promotion. (WHO 1986:1, Nutbeam, 1998: 350).
Figure 1: The main determinants of health. By Dahlgren and Whitehead 1993.
Determinants of health refer to the range of social, economic and environmental factors which determine the health status of individuals or populations Health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to take into account differing social, cultural and economic systems. (WHO 1986:4)
The Ottawa Chatter recognises three major strategic approaches for health promotion:
Advocacy – a combination of individual and social actions designed to gain political
commitment or support for a particular health goal or program (Nutbeam, 1998: 350).
Enabling – working with others in a participative manner; and
Health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to take into account differing social, cultural and economic systems. (WHO 1986:4)
The Jakarta Declaration on Leading Health Promotion into the 21st Century from July 1997 confirmed that these strategies and action areas are relevant for all countries; that comprehensive approaches to health development are the most effective; that settings for health offer practical opportunities for the implementation of comprehensive strategies; that participation is essential to sustain efforts and that health literacy/health learning fosters participation. (Nutbeam 1998:351)
The Bangkok Charter for Health Promotion in a Globalized World from August 2005 went further to recognise some critical factors that newly influence health which include: commercialization, increasing inequalities within and between countries, new patterns of consumption and communication, global environmental change and urbanization; as well as the new opportunities for cooperation which globalization has opened up to improve health and reduce transnational health risks. (WHO 2005:1)
Other strategies and key competencies include:
Health Communication – the use of communication techniques and technologies to
positively influence the health of individuals, populations and organizations
Health Education – consciously constructed opportunities for learning improve
health literacy, including improving knowledge and developing life skills to enhance health.
Self-Help/Mutual Aid – a process by which people who share common experiences,
situations or problems can offer each other support.
Organizational change – working within settings for health, to create supportive
environments that better enable people to make healthy choices.
Community Development and Mobilization – collective efforts by communities which
are directed towards increasing community control over the determinants of health
Policy Development – developing legislative and regulatory measures that protect the
1.4.WHAT HAS CHANGED?
Health Promotion is an evolving discipline; the concept of Health Promotion has further developed since Ottawa in a sequence of international conferences and by many stakeholder groups. Although the Ottawa Charter has been phenomenal in guiding its development, the world has changed a lot since 1986 and there has since been a broadening of the discipline to encompass wider agenda (Nutbeam 2008: 435). The WHO’s first Health Promotion glossary was first published in 1986 with 69 definitions of core concepts and principles used in the field (Smith 2006: 340). This was first revised in 12 years later with a re-definition of basic terms as well inclusion of new concepts and issues such as disease burden, capacity building global health and social marketing (Nutbeam 1998: 350; Smith 2006: 342). There has also been a recent emphasis on chronic non-communicable diseases, with new challenges including economic, legal and environmental policies, modifying risk factors, poverty and urbanization. Not that the science and understanding of non-communicable diseases have advances so significantly, it is because there has been a paradigm shift in the way in which public health problems are conceptualized and addressed (WHO 2005; Nutbeam 2008: 435).
2. A SENSIBLE DRINKING PROGRAMME: BEATTIE MODEL APPLIED 2.1.INTRODUCTION AND MOTIVATION
The harmful use of alcohol is a worldwide problem resulting in millions of deaths. It accounts for about 4% of the global burden of disease; alcohol ranks eighth among global risk factors for death, while it is the third leading global risk factor for disease and disability (WHO 2011: 31). It is not only a causal factor in many diseases, but also a precursor to injury and violence (Rossow 2000: 398); and its negative impacts can spread throughout a community and beyond. Alcohol consumption causes harm far beyond the physical and psychological health of the drinker. It also causes harm to the well-being and health of others. Social harm from drinking can be defined in terms of how they affect important roles and responsibilities of everyday life: work, family, friendship and public character. (WHO 2011: 34). Hence it becomes imperative to review a comprehensive picture of harmful alcohol use and its health consequences and to employ effective interventions aimed at reducing alcohol-related problems, considered within a health promotion framework.
2.2.SCOPE
Drinking behaviour is shaped by individual choices and motivation, and also strongly influenced by organizational, economic, environmental, and social factors (WHO, 2004: 22). Therefore, approaches that attempt to bring about change in drinking behaviour through health education in combination with behavioural, environmental, policy and organizational changes are likely to be the most effective.
The goal of this programme is to modify the drinking pattern by reducing the volume, the frequency, modify the variability, encourage abstinence, discourage heavy drinking including heave episodic ‘binge’ drinking. (WHO 2004: 22)
While no single theory dominates the health promotion practice given the range of health problems and their determinants (Nutbeam and Harris 1999:15), the Beatties Model of Health promotion is employed in the planning and implementation of this programme.
Figure 2: Using Beattie’s model to analyse Health Promotion. Based on Beattie 1991, 1993
The Beattie’s model consists of four quadrants, arranged on two axes. The two axes represent ‘mode of intervention’ which can be authoritative (a top down approach) or negotiated (a bottom up approach) and ‘focus of intervention’ which can be individual or collective. The Beatties model suggest that in addressing a health issue, all the four approaches should be used to form a coherent strategy. This is because not all determinants of alcohol use can be tackled by using a single approach, but if the model is
applied, it is more likely that a greater range of social, environmental and economic determinants will be addressed. (Warwick-Booth et al 2012:158).
2.3.AUDIENCE
This programme reaches out to people, groups and organizations that are critical to the achievement of health in this community, including the government and politicians, civil society, the private sector, non-governmental organizations and the public health community.
2.4.HEALTH PERSUASION
Health persuasion is addresses the individuals and the practitioner plays the role of the expert. The aim is to persuade and encourage people to adopt healthier lifestyles. Individual Authoritative:
Advice Education
Behaviour change Mass-media campaign
Media advocacy and public communication efforts do have significant benefits in health persuasion and can help shape the community. There is evidence that well devised and adequately resourced programs incorporating mass media can improve health related
behaviours (Peter Howat et al 2004: 172). Advertising campaigns can encourage quitting,
so is counter advertising where necessary. The focus of these campaigns is most frequently on drink–driving, youth drinking, alcohol and health, and social harm related to alcohol use. The other category most commonly included focuses on domestic or family violence, and alcohol use (WHO 2011: 52).
Communications channels are also important. While mass media channels are effective in disseminating information about innovations to many people, peers are highly
influential in a person’s decision to adopt an innovation. (Downie R.A.S et al 1996:
134)Thus, using social networks to reinforce mass media messages is more effective than mass media alone. In addition, when respected local leaders initiate or reiterate information provided through mass media channels, the chances increase that individuals and groups will decide to act which is consequently likely to be more sustainable.
A combination of popular leaders’ recommendations, peer group approval, and mass media messages, especially if enhanced by coordinated listening groups, call-in opportunities, and face-to-face approaches, is a powerful impetus to adopt an innovation. Other methods include use of leaflets/publications, policy and guidance, press centre, multimedia centre, blogs, speeches, feature stories, newsletter, etcetera
2.5.PERSONAL COUNSELLING
Individual Negotiated: Counselling
Education Group work
Personal counselling is aimed at individuals, but issues are client-defined, client-led and focus on personal development in order to empower them to have the skills and confidence to take control over their health (Louise Warwick-Booth 2012: 155).
Practitioner is in the role of counsellor, working with people’s self-defined needs; for example, a young man engaging in heavy drinking as a way of relieves the boredom of not being able to get a job, the practitioner may facilitate him in developing skills and opportunities for work, or volunteering opportunities that can contribute to work experience.
School programs grounded in educational and behavioural change theory often result in positive outcomes and have been generally with life skills training to target drinking behaviours of young people. Likewise, tertiary institution programs are helpful. High-risk students who were provided with a brief intervention based on principals of motivational interviewing showed significant reductions in drinking rates and harmful consequences, as well as a significantly greater deceleration of drinking rates and problems over time (Peter Howat et al 2004: 171)
Other activities include increasing availability of self-help/advice resources at GP practices, pharmacists, workplaces; developing a smartphone apps to be used alongside sensible drinking programmes.
2.6.LEGISLATIVE ACTION
Collective Authoritative:
Legislation
Policy-making and implementation
These are set of measures in a jurisdiction, social and other policies imposed on the populations and aimed at protecting the population minimizing the health and social harms from alcohol consumption. These measures may be in any governmental or societal sector, and may include measures which are not directly aimed at alcohol consumption (WHO 2012:40). The health practitioner plays in the role of custodian, knowing what will improve the nation’s health
Pricing policies are regarded as among the most effective measures to reduce total alcohol consumption and hence alcohol-related problems. Studies have indicated that a rise in price will lead to a drop in consumption and a decrease in price will likely result
in additional alcohol related deaths (Peter Howat et al 2004: 168, WHO 2012:42)
Other legislative actions include
Raising the drinking age – this has be found to be associated with a reduction in
alcohol consumption and alcohol related problems among young people.
Placing restrictions on advertising and promotion of alcohol products – because
advertising and promotion act as reinforcing factors for alcohol consumption particularly by young people
Alcohol Licensing and Alcohol Availability: There is substantial evidence that alcohol
availability is correlated with levels of consumption and ultimate harm; and prevention regulations that are aimed at the sellers of alcohol are more effective than prevention programs that rely only on education directed at individual drinkers. A common means of controlling alcohol distribution is through government-sanctioned licensing systems. (WHO, 2012: 43).
Server intervention and drinking environments: Server intervention programs
involve training servers employed to serve alcohol beverages in alcohol retail establishments, including managers and door staff. Their main objective is to prevent intoxication and drunk driving by their clients. Recommended serving practices include providing food, slowing service to drinkers showing signs of intoxication, refusing service to intoxicated or underage drinkers, and taking steps to prevent
2.7.COMMUNITY DEVELOPMENT Collective Negotiated: Lobbying Action research Group work Community development
Skills sharing/ training
Community development has been defined as actions that helps people to recognize and develop themselves to respond to problems and needs that they share, to enfranchise or emancipate groups and communities so they can recognize what they have in common and how social factors influence their lives. (Louise Warwick-Booth 2012: 157). Here, the practitioner is in role of advocate. Community development approaches are linked to empowerment and communities that take action for themselves in addressing health and the wider determinants of health.
For example, the residents may lobby the local council regarding whether or not to grant licence to businesses to sell alcohol in their area. There may also be community initiative to tackle anti-social behaviour in young people by encouraging other forms of activities to relieve boredom, such as community clubs owned and governed by young people themselves.
Other community development activities may include the following:
Promoting the formation of community support groups
Developing a mentorship system between ex-addict and current heavy drinker
Designing a competition at the workplace to encourage employees to quit collectively
2.8.SUMMARY
Effective health promotion leads to changes in the determinants of alcohol related problems, both those within the control of individuals (such as decision-making) and those outside their direct control in the social, economic and environmental arenas. The
most effective means of changing drinking behaviour is through a combination of educational, organizational, economic and political actions.
3. BEATTIE’S MODEL IN CONTEMPORARY HEALTH PROMOTION
The Beatties model is a useful model for health promoters as it identifies a clear framework for deciding a strategy and reminds them of the choice of intervention that is influenced by social and political perspectives. Beattie’s model supports the notion, that contemporary health promotion should not focus exclusively on any one single element, such as disease prevention, or societal change (Tannahill 2008) by allowing us to analyse the complexities of health promotion approaches and by demonstrating that many agencies with many different approaches across all quadrants and axes are needed for well-rounded health promotion policies and practice. Beattie’s model of health promotion is a complex analytical model that acknowledges that health promotion is ‘embedded in wider social and cultural practices’ (Wills and Earle 2007, Chapter 5). Beattie's model empowers both the person and community and concurs with the Ottawa Charter.
The four quadrants represent the different ways in which health can be promoted by professionals, governments, and individuals, through health persuasion techniques, legislative action, personal counselling and community development. (Thomas and Stewart 2005; Naidoo and Wills 2007, Chapter 5; Wills and Earle 2007, Chapter 5).
Governments and health care professionals typically work in a ‘top down’ authoritative approach, through legislative action and health persuasion techniques. Here, advice and recommendations are handed out, and policies and interventions designed to increase uptake of these recommendations are established. The aim of this is to protect individuals and communities. However, both of these approaches on their own may disempower individuals through a ‘victim blaming’ culture and may therefore result in only limited change (Thomas and Stewart 2005).
The personal counselling approach and the community development approach both seek to negotiate health, empower and enhance knowledge, understanding, and skills. With the personal counselling approach, this is achieved through a health professional assisting the individual to develop and reach their goals, rather than acting as an expert
instructing them how to change. The community development approach is similar to this, except that rather than focusing on individuals, the focus is on groups, such as local community groups (Naidoo and Wills 2007, Chapter 5). Community development does require an ‘enabler’ or facilitator who will help to drive the project, but the risk then is whether this facilitator brings their own agenda to the project, thereby diverting resources towards their own objectives rather than those of the community at large (Thomas and Stewart 2005).
However the Beattie’s model does not give priority to issues like investment for health, commercialization, global environmental change, and urbanization; including investing in research evaluation, and its dissemination; collaboration, cooperation and integration between sectors especially the corporate sector.
REFERENCES
Birn A.E, Pillay Y., & Holtz T.H., (2009). Ch. 4. The Political Economy of Health and
Development. Textbook of International Health. Global Health in a Dynamic World. New York: Oxford University Press: 132-140
Downie R.A.S., Tannahil, C. & Tannahill D. (1996). Health Promotion Models and Values.
Oxford Medical Publications
Ewles and Simnett 1999.
Green L. (1979). National policy on the promotion of health. International Journal of Health Education 1979 (22):161-168
Linda Ewles, Ina Simnett (1999). Promoting Health: A Practical Guide. Baillière Tindall:
New York
Louise Warwick-Booth, Ruth Cross, Diane Lowcock (2012) Contemporary Health Studies:
An Introduction Polity press, UK
Nutbeam D., (1998). Health Promotion Glossary. Health Promotion International,
13(4):349-364
Nutbeam D., (2008). What would the Ottawa Charter look like if it was Written Today?
Critical Public Health, 18 (4): 435-441
O'Donnell M. P. (2009) Definition of Health Promotion 2.0: Embracing Passion, Enhancing
Motivation, Recognizing Dynamic Balance, and Creating Opportunities. American Journal of Health Promotion: September/October 2009, Vol. 24, No. 1, pp. iv-iv.
Peter Howat, David Sleet, Bruce Maycock And Randy Elder (2004) Effectiveness of Health
Promotion in Preventing Alcohol Related Harm. Cutis University, Western Australia
Rossow, I. (2000). “Suicide, violence and child abuse: A review of the impact of alcohol
consumption on social problems”, Contemporary Drug Problems, vol. 27, no. 3, pp. 397– 433.
Smith B.J., Tang K.C., & Nutbeam D., (2006). WHO Health Promotion Glossary: New Terms.
Vetter N, Matthews I. (1999) Epidemiology and public health medicine. Churchill Livingstone.
WHO (2005). The Bangkok Charter for Health Promotion in a Globalized World. WHO,
Geneva
Wills, J. and Earle, S. (2007). Theoretical perspectives on promoting public health. In
Theory and research in promoting public health. Earle, S., Lloyd, C. E., Sidell, M. and Spurr, S., Sage, London / The Open University, Milton Keynes.
Thomas, S. and Stewart, J. (2005). Optimising health promotion activities. Journal of
Community Nursing 19(1): 9-12.
Naidoo, J. and Wills, J. (2007). Models and approaches to health promotion. in Health
promotion: Foundations for practice. Naidoo, J. and Wills, J., Bailliere Tindall / Royal College of Nursing.
Tannahill, A. (2008). Health promotion: The Tannahill model revisited. Public Health 122:
1387-1391.
Tones, K. (1987). Devising strategies for preventing drug misuse: the role of the Health
Action Model Health Education Research 2(4): 305-317.
World Health Organization (1986). Ottawa Charter for Health Promotion. WHO, Geneva
World Health Organization 2004. Global Status Report on Alcohol. WHO, Geneva.
