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Promoting Health
To Jon and Sara

Commissioning Editor: Mairi McCubbin

Development Editor: Sally Davies
Project Manager: Elouise Ball
Designer: Kirsteen Wright
Illustration Manager: Merlyn Harvey
Promoting Health
A Practical Guide

Angela Scriven BA(Hons) MEd CertEd FRSPH MIUHPE

Reader in Health Promotion, Brunel University, London, UK

Forewords by
Linda Ewles BSc MSc MA

Ina Simnett MA(Oxon) DPhil CertEd

Bristol, UK

Richard Parish BSc Med PDHEd CBiol MIBiol FRSPH FFPH CMIPR HonMAPHA
Chief Executive, Royal Society for Public Health, London, UK

SIXTH EDITION

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2010
© 2010 Elsevier Ltd. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
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permission, further information about the Publisher’s permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

First edition 1985

Second edition 1992
Third edition 1995
Fourth edition 1999
Fifth edition 2003
Sixth edition 2010

ISBN: 978 0 7020 3139 7

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.

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 v

Contents

Forewords vii 8 Skills of personal effectiveness 107

Preface xi
Acknowledgements xiii 9 Working effectively with other people 121

PART 1 THINKING ABOUT HEALTH PART 3 DEVELOPING COMPETENCE

AND HEALTH PROMOTION 1 IN HEALTH PROMOTION 131

1 What is health? 3 10 Fundamentals of communication 133

2 What is health promotion? 17 11 Using communication tools in health promotion

practice 147
3 Aims, values and ethical considerations 31
12 Educating for health 163
4 Who promotes health? 45
13 Working with groups 177

PART 2 PLANNING AND MANAGING FOR 14 Enabling healthier living 191

EFFECTIVE PRACTICE 61
15 Working with communities 207
5 Planning and evaluating health promotion 63
16 Influencing and implementing policy 223
6 Identifying health promotion needs
and priorities 77 Glossary 235

7 Evidence and research in health Index 241

promotion 91
This page intentionally left blank
 vii

Foreword

We are delighted that Promoting Health is now in its and amalgamated) approached us for an updated
sixth edition. edition.
We embarked on writing the first edition back But the last request for a new edition came at the
in the early 1980s. One of us (Linda Ewles) was stage in our lives when we had both retired from
then working at Bristol Polytechnic (now the Uni- work in health promotion. We felt that the update
versity of the West of England) running one of should be done by someone in closer touch with
the three postgraduate Diploma courses in health current professional thinking and practice. We are
education which existed in the UK at that time. The delighted that Angela Scriven undertook the task
other (Ina Simnett) had recently moved to Bristol and has given the book a new lease of life with a
and was working in health education in the NHS. thoroughly updated version which still retains the
We had each independently recognised the need style and scope of its predecessors. We are very
for a health education textbook; amazing as it grateful to her for her excellent work.
seems now, at the time there were none in the UK. Twenty-five years after the first edition was
We were put in touch with each other by Jane written, we can look back and see that some themes
Randell who did much to develop education and we wrote about then are still totally relevant today.
training at the national Health Education Council. Health promoters still need to explore what ‘health’
It was the start of our long collaboration and means, understand the underlying values and
friendship. approaches in health promotion, think about ethical
We put together an outline of the book’s pro- issues, base their work on evidence of effectiveness
posed content, drawing heavily on our combined and learn skills of communicating and managing,
experience and training. We typed the chapters on planning and evaluating. A surprising amount
a manual typewriter (no word processors then) and of the sixth edition has scarcely changed since the
laboriously looked up all the references in libraries first one.
(no Internet). Our first publisher was John Wiley, But of course a great deal has changed, and this
and Promoting Health: A Practical Guide To Health is reflected in the current edition. We are struck by
Education was launched in May 1985 at a nursing the huge expansion of the evidence base of ‘what
conference in Harrogate. works’ and how much research and information is
We fully expected that the book would have a now available on the Internet. In terms of delivering
shelf life of a few years, and then be superseded by health promotion, the rise of partnership working
many others. Indeed, more textbooks on health between sectors and agencies and the integration of
education and health promotion (when that new health promotion specialist work in the NHS into
term started to be used) did appear – but ours con- mainstream public health (rather than remaining a
tinued to be well used. We had met a need. Every Cinderella ‘add-on’ service) are also remarkable.
few years from then on, our publisher (who changed Health promotion has become an integral part of
several times as publishing companies were sold basic training for health workers and there has
viii Foreword

been a massive growth in specialist training of Asia and the Middle East. We are pleased to think
opportunities. that we must have got something right! We would
Some health education acorns undoubtedly also like to take this opportunity to thank all those
failed to take root, but others have become sturdy people who, in so many different ways, have helped
oak trees. For example, stop-smoking group work to make Promoting Health a success.
by a few health educators has grown into a huge Of course, as Richard Parish points out in his
mainstream NHS smoking cessation programme. Foreword, health promoters now face 21st-century
A handful of health workers going into schools to challenges, such as obesity, alcohol consumption
give talks has developed into a European-wide levels, climate change and new forms of communi-
health-promoting schools network with fully- cable diseases. We hope that this edition continues
fledged personal, social and health education school to contribute to the spread of sound health pro­
programmes. motion practice in tackling these and other issues
We are gratified and humbled to think that our which undermine health today. We also hope that
book has made a small contribution to these and it helps people to continue their efforts to reduce
other developments over the last 25 years. It has health inequalities in the UK and across the
been widely used in the UK but also in over 50 world.
countries around the world. It has been translated Linda Ewles
into seven European and Asian languages and has Ina Simnett
been useful in health development in Africa, parts
 ix

Foreword

The need for effective health promotion has never The challenge of better health requires action at
been greater. We face immense challenges to health all levels of society. Government and the national
as we move through the 21st century. Regrettably, agencies most certainly have a major role to play,
modern-day life is not always as conducive to not least in supporting those who work to improve
health and wellbeing as we would wish. The current health. The following pages provide an authorita-
scourge of overweight and obesity is but one tive text for everyone involved in promoting health,
measure of our unhealthy lifestyles. To this we must both informing policy makers as to what is possible
add the growing impact of climate change and the and acting as a toolkit for health promoters. From
emergence of new strains of communicable disease. planning and management to monitoring and eval-
Never before have we faced such an assault upon uation, this edition ranges across the full panoply
our health, with the disadvantaged suffering the of tools and techniques. It is genuinely a practical
greatest. guide, helping to ensure effective practice in every
The forces waged against health are complex and area of health promotion work.
comprehensive. We need a skilled and competent Promoting Health: A Practical Guide is not just for
workforce if we are to improve health for all over health promotion specialists responsible for deliv-
the coming years. The earlier editions of Promoting ering better health to the communities with which
Health: A Practical Guide have been heavily used by they work. It also describes the potential for health
students, academic staff in universities and col- promotion. As such, it is an essential tool for com-
leges, policy makers and planners, and by health missioners and those who plan and procure health
promoters going about their everyday work. This improvement services, helping to define how best
new edition will continue the tradition of this to invest public resources.
seminal publication and will strongly influence the Better health will only be achieved through
training of future practitioners. Building on its rich actions at all levels of society. The state and the
pedigree, this latest edition tackles the major health public sector, commercial organisations, voluntary
issues facing us today, focusing on practical inter- agencies and individual citizens all have a role to
ventions for better health. play. This book will help ensure effective and effi-
Many strategies and techniques in health promo- cient action. We must deploy our resources to
tion are tried and tested. There is a sound and maximum advantage, for the cost of not doing so
growing evidence base. We know what works in will be measured in avoidable ill health, unneces-
most situations, although we must be ever vigilant sary expenditure and a loss of human potential. To
in pursuing new approaches and evaluating the this end Promoting Health: A Practical Guide is a valu-
outcomes. Effective health promotion draws on able investment.
many disciplines, adapting to the emergence of new Richard Parish
evidence. This book reflects contemporary think-
ing, referring to the application of new technologies
and approaches such as social marketing.
This page intentionally left blank
 xi

Preface

The aim of this book is to provide an accessible ● Who needs health promotion and what are
practical guide for all those who practise health these needs?
promotion in their everyday work. It was first pub- ● How can priorities be set?
lished in 1985, and in response to demand a new ● How can health promotion be planned,
updated edition has been produced approximately managed and evaluated?
every five years. Earlier editions have also been ● How can health promoters best carry out health
published in German, Hungarian, Finnish, Greek, promotion? What are the competencies they
Indonesian, Italian and Swedish. require?
The book is addressed to all those who promote
● What are the key issues for health promotion?
health, including health promotion and public
health practitioners and specialists, hospital and There is a focus on the theories, principles and com-
community nurses, health visitors and midwives, petencies you need to consider, whatever your
hospital doctors and general practitioners, dentists background and wherever you work. The range of
and dental hygienists, pharmacists, health service health issues and settings for health promotion
managers and the professions allied to medicine. It (such as communities, schools, workplaces, GP
is also for the wide range of health promoters in surgeries or hospitals) is clearly enormous, but it
statutory and non-statutory agencies, for example is beyond the scope of this book to cover all these
local authority staff such as environmental health in depth. Different professional groups will all
officers and social workers, voluntary organisa- have their own areas of expert knowledge and spe-
tions, youth and community workers, teachers in cialist skills to be employed alongside the specific
schools, colleges and universities, probation offic- expertise in promoting health addressed in this
ers, prison officers and police officers. book.
Health promotion encompasses a wide variety of As in previous editions, the book is organised
activities, with the common purpose of improving into three parts. Part 1 Thinking About Health and
the health of individuals and communities. This Health Promotion deals with basic ideas of what
book is concerned with the what, why, who and health, health promotion and health education are
how of health promotion. It aims to help you about, and the different approaches and ethical
explore important questions such as: issues that need to be considered, and identifies the
agencies and people who have a part to play in
● What is health?
health promotion and public health.
● What affects health? Part 2 Planning and Managing for Effective Practice
● What is health promotion? How is it part of a looks at planning and evaluation at the level of a
wider public health movement? health promoter’s daily work and starts by intro-
● Who are the agents and agencies of health ducing a basic planning and evaluation framework.
promotion? It continues with a discussion of how to identify
xii Preface

and assess needs and priorities, and develop skills website addresses, to reflect the increased use of the
to manage yourself and your work effectively. internet to disseminate health information and evi-
Part 3 Developing Competence in Health Promotion dence, with such networking sites as Twitter and
looks at how you can develop your competence in YouTube being used in a health-promoting capac-
carrying out a range of activities, including en­­ ity by the Department of Health, non-governmental
abling people to learn in one-to-one and group set- organisations and community health groups.
tings, enabling people towards healthier living, Non-sexist writing is used throughout the text,
working with communities and changing policies drawing on the ideas on non-sexist writing dis-
and practices. The fundamentals of communi­­ cussed in Chapter 11. Several terms have been
cation and of using communication tools are also used to describe the people that health promotion
addressed. targets. These terms include ‘patients’ (referring
This sixth edition is fully revised and updated to mainly to those who receive their health promotion
take account of recent developments in public in a healthcare environment), ‘clients’ (for patients
health, such as revised national strategies for health, and non patients) or simply users, individuals or
reorganisations that have taken place in the National groups. The term ‘health promoters’ is used to
Health Service, and new policies that have a bearing cover the multidisciplinary workforces that have
on the promotion of health. It is important to note, remits for promoting health, but whose job titles
however, that policies and strategies for health fre- cover a wide spectrum, including public health
quently change, particularly when governments practitioners (see Ch. 2 for a discussion on who
change, and there will be a general election during promotes health).
the life of this sixth edition. It is likely, therefore, The overall aim of the book is the same as in
that some of the policies referred to in the text may previous editions, to keep you involved, so that
have been replaced. New issues that are highlighted studying this book will be an active educational
are: experience. Exercises are included to undertake as
● changes to the structure and organisation of the an individual or in a group, and examples and case
National Health Service in the UK studies are provided to help you to apply ideas
● national standards for work in health
to your own situation. Often the exercises are
promotion and public health designed to stimulate thought and discussion and
there may be no right answers. You will need to
● new research on the comparative effectiveness
think it through, talk it over and reflect. In this way
of different approaches to health promotion
the answers will have personal meaning and
● reference to new technology, especially the
application.
Internet London, 2010 Angela Scriven
● new approaches, including social marketing.
The user-friendly style adopted in the previous
editions has been retained. There are many more
 xiii

Acknowledgements

Linda Ewles and Ina Simnett, the authors of the first elements of the book have been strongly influenced
five editions of this book, produced a seminal text by the work of others. Many of these remain and
that I and many others have used in the training have been further adjusted to suit the current needs
and education of health promoters over the last 25 of health promoters. Finally, I would like to thank
years. Their book has shaped health promotion Professor Richard Parish for his Foreword, and for
practice in the UK over this time. I am privileged to their support and encouragement throughout the
have been invited to take over the authorship and process of producing this new edition, Sally Davies
wish to thank Ewles and Simnett and Elsevier, the and Mairi McCubbin from Elsevier, my colleague
publishers, for giving me this opportunity. I also Sebastian Garman at Brunel University and my
wish to thank all of those who had an involvement family and friends.
in the first five editions. Some of the exercises and
This page intentionally left blank
 15

PART 1

Thinking about health and

health promotion

Part Contents
1. What is health? 3
2. What is health promotion? 17
3. Aims, values and ethical considerations 31
4. Who promotes health? 45

Part Summary
Part 1 has three purposes: There is also an historical overview of some of the
● It sets the context for the whole book, by international and national movements that have
introducing key concepts, principles and ideas worked towards better health.
and by providing you with a common language in In Chapter 2 health promotion is defined and shown
which to communicate about health promotion. to encompass a wide range of activities. Frameworks
● It offers an introduction to the dimensions and
are given for classifying the major areas of health
scope of health and health promotion, which enables promotion action. Occupational standards are outlined
you to focus on the wide range of activities and and an exercise is provided to help you to explore the
approaches being utilised by health promoters. scope of your health promotion work.
In Chapter 3 the aims and values associated with
● It highlights important philosophical and ethical
different approaches to health promotion are analysed,
issues, which are explored in a practical context
a number of ethical dilemmas are examined and guid-
later in the book.
ance is provided on how to make ethical decisions.
Health is an extremely difficult word to define but it is In Chapter 4 the agents and agencies of health
clearly important that you know what it means. This is promotion are identified and there is an opportunity to
discussed in Chapter 1, along with a description of the clarify your own health promotion role.
major influences on health and inequalities in health.
This page intentionally left blank
 3

Chapter 1
What is health?

Summary
Chapter Contents
This chapter starts with an exercise which enables
What does being healthy mean to you? 3 you to examine what being healthy means to you,
and reviews the wide variation in people’s concepts of
Concepts of health 4
health. Dimensions of health are considered (physical,
What affects health? 7 mental, emotional, social, spiritual and societal)
and health is explored as a holistic concept. Factors
Improving health – historical overview 10
that affect health are identified, with a particular
International initiatives for improving health 11 focus on medicine and inequalities in health. Case
studies illustrate the factors that shape the health of
National initiatives 12
people in differing circumstances. In the final section
Where are we now? 13 there is a historical overview of the contribution of
international and national movements towards better
health.

What Does Being Healthy Mean

to You?

Being healthy means different things to different

people, and much has been researched and written
about people’s varying concepts of health (see, for
example, Hughner & Kleine 2004 and Earle 2007).
It is fundamental that you, as a health promoter,
explore and define for yourself what being healthy
means to you and what it may mean to your clients.
This is the aim of Exercise 1.1.
Exercise 1.1 generally shows that different people
identify different aspects of being healthy as impor-
tant. What you choose is often a reflection of your
particular circumstances at the time, your experi-
ences and/or your professional background. For
example, if you are feeling stressed at work you
may consider enjoying work without too much
4 Promoting Health: A Practical Guide

EXERCISE 1.1 What does being healthy mean to you?

In Column 1, tick any of the statements that seem to you to be important aspects of your health. Tick as many as you
like.
For me, being healthy involves: Column 1 Column 2 Column 3
1. Enjoying being with my family and friends ■ ■ ■
2. Living to a ripe old age ■ ■ ■
3. Feeling happy most of the time ■ ■ ■
4. Having a job ■ ■ ■
5. Hardly ever taking tablets or medicines ■ ■ ■
6. Being the ideal weight for my height ■ ■ ■
7. Taking regular exercise ■ ■ ■
8. Feeling at peace with myself ■ ■ ■
9. Never smoking ■ ■ ■
10. Never suffering from anything more serious than a mild cold, ■ ■ ■
flu or stomach upset
11. Not getting things confused or out of proportion – assessing ■ ■ ■
situations realistically
12. Being able to adapt easily to big changes in my life such as ■ ■ ■
moving house or a new job
13. Drinking only moderate amounts of alcohol or none at all ■ ■ ■
14. Enjoying my work without too much stress ■ ■ ■
15. Having all the parts of my body in good working condition ■ ■ ■
16. Getting on well with other people most of the time ■ ■ ■
17. Eating the ‘right’ foods ■ ■ ■
18. Enjoying some form of relaxation or recreation ■ ■ ■
In Column 2, tick the six statements which are the most important aspects of ‘being healthy’ to you.
Then in Column 3, rank these six in the order of importance – put 1 by the most important, 2 by the next most
important and so on down to 6.
If you are working in a group, compare your list with other people’s. Look at the similarities and differences, and
discuss the reasons for your choices.
(Adapted with kind permission from Open University 1980.)

stress as important, or if you work in a smoking Lay Perceptions

cessation service you may prioritise not smoking as
a crucial aspect of being healthy. As your circum- It is important to understand the way lay people
stances change, your idea of what being healthy think about health and wellness, as this influ­­
means to you is also likely to change. ences their health and wellness-related behaviours
(Hughner & Kleine 2004). Researchers have found
a wealth of complex lay notions about health. Some
Concepts of Health lay perceptions are based on pragmatism, where
health is regarded as a relative phenomenon, expe-
As Exercise 1.1 will have indicated, health is a dif- rienced and evaluated according to what an indi-
ficult concept to define in absolute terms. The vidual finds reasonable to expect, given their age,
meaning can be culturally and professionally deter- medical condition and social situation. For them
mined and has changed over time (Thomas 2003). being healthy may just mean not having a health
A variety of definitions and explanations of what it problem which interferes with their everyday lives
means to be healthy exists (Duncan 2007) and none (Bury 2005). Thomas (2003) has classified some
can be deemed to be right or wrong. personal constructs of health into models. The
 Chapter 1 What is health? 5

functional model, for example, is based on social role Because of this variety and complexity of the
performance and social normality, rather than ways in which people conceptualise health, it is
physical normality; the psychological model empha- difficult to measure health.
sises the ability to deal with stress and having resil- For more about measuring health, see Chapter 6,
ience. Whatever the lay understandings of health section on finding and using information.
are based on, however, they illustrate that lay
accounts are unique, and health and strategies for
health must be individualised. For example: Professional Concepts of Health
● Homeless, single young people in Scotland Professional concepts of health have changed
viewed their health in terms of functional over time. In the late 19th and 20th century, as
concepts such as taking regular exercise and medical discoveries were made and medical prac-
getting a good night’s sleep. In this respect, tice developed, there was a preoccupation with a
health was seen as a tool for everyday living mechanistic view of the body and consequently
(Watts et al 2006). with physical health. Earlier still, there have been
● Lay men’s understanding of health and centuries of many philosophies of health in differ-
wellbeing has been shown in a study to relate ent civilisations, such as Greek and Chinese, where
to notions of control, and the associated issues a more holistic view of health has been held. See
of risk and responsibility. Specifically, men saw Lloyd & Sivin (2002) for a comparison of these two
health in more psychological terms (Robertson cultures and their view on health, science and
2006). medicine.
● Exploration of children’s concepts of health has One way of understanding the various meanings
shown that their ideas of being healthy and that the different professional groups hold is to
what makes them healthy are strongly tied up put health into broad categories or models. Three
with notions of infection; health for them is the models are identified below and include the medical
lack of symptoms like a cough or running nose. model, the holistic model, and the wellness model.
Children in the study also linked
environmental pollution with health, with The medical model
smoking seen as an environmental pollutant, ● The medical model dominated thinking about
but did not mention violence, being homeless health for most of the 20th century.
or similar social factors among health ● Health is defined and measured as the absence
determinants (Piko & Bak 2006). of disease and the presence of high levels of
function.
Concepts of health, illness and disease have gener-
● In its most extreme form, the medical model
ally been linked with people’s social and cultural
situations. Knowledge of illness, prevention and views the body as a machine, to be fixed when
treatment can also be powerful in shaping people’s broken.
concept of health. Such knowledge may be part of ● It emphasises treating specific physical
a cultural heritage, passed on through generations diseases, does not accommodate mental or
(Kue Young 2005). social problems well and de-emphasises
Standards of what may be considered healthy prevention.
also vary. An elderly woman may say she is in good
health on a day when her chronic arthritis has The holistic model
eased up enough to enable her to get to the shops. ● The holistic model was exemplified by the
A man who smokes may not regard his early World Health Organization (WHO) constitution
morning cough as a symptom of ill health, because which referred to health as a state of complete
to him it is normal. People assess their own health physical, mental and social wellbeing and not
subjectively, according to their own norms and merely the absence of disease or infirmity
expectations. (WHO 1948).
People may also trade-off different aspects of ● This broadened the medical model perspective,
health. A common example is that people may and highlighted the idea of positive health,
accept the physical health damage from smoking as although the WHO did not originally use that
the price they pay for the emotional benefit. term, and linked health to wellbeing.
6 Promoting Health: A Practical Guide

● The WHO definition is in many ways difficult that these conceptions run the risk of excessive
to measure. This is less because of the breadth, of incorporating all of life. Thus, they do
complexity of measuring wellbeing, as not distinguish clearly between the state of being
psychologists have done (for example White healthy and the consequences of being healthy; nor
2007), but more because doing so required do they distinguish between health and the deter-
subjective assessments that contrast sharply minants of health (some of the above is adjusted
with the objective indicators favoured by the from http://courseweb.edteched.uottawa.ca).
medical model. It is important to note that the WHO (1948)
constitution definition of health mentioned above
The wellness model has been heavily criticised, mainly on two grounds:
● In 1984, a WHO discussion document
it is unrealistic and idealistic and it implies a
proposed moving away from viewing health static position. A study by Jadad & O’Grady (2008)
as a state, toward a dynamic model that found that some criticisms of the WHO definition
presented it as a process or a force (WHO focused on its lack of operational value and the
1984). This was amplified in the Ottawa Charter problem created by use of the word ‘complete’. An
for Health Promotion which proposed that health extreme critique, such as Smith (2008), call it a ludi-
is the extent to which an individual or group is crous definition that would leave most of us
able to realise aspirations and satisfy needs, unhealthy most of the time. In support of the defi­
and to change or cope with the environment. nition, Jadad & O’Grady (2008) argue that the
Health is seen as a resource for everyday life, WHO invited nations to expand the conceptual
not the objective of living; it is a positive framework of their health systems beyond the tra-
concept, emphasising social and personal ditional boundaries set by the physical condition of
resources, as well as physical capacities individuals and their diseases, and it challenged
(WHO 1986). political, community and professional organisa-
● Related to this is the notion of resiliency, such tions devoted to improving or preserving health to
as the success with which individuals and pay more attention to the social determinants of
communities adapt to changing circumstances health.
(see Antonovsky 1979 and 1987, and his Sense Even just using these three broad categories of
of Coherence theory). health, it follows that there will be differences
There are advantages and disadvantages to each of between health practitioners’ concepts of health. To
these models. The advantage of the medical model take one example, practitioners of complementary
is that disease represents a major public health issue medicine hold to a range of beliefs about what
facing society, and disease states need to be treated health is and how health can be restored or
and can be readily diagnosed and counted. But improved which is based on holism and em­­
this approach is narrow, negative and reductionist, powerment (Barrett et al 2004).
and in an extreme form implies that people with In exploring the concept of health further it is
disabilities are unhealthy, and that health is only useful to consider the identification of different
about the absence of morbidity. A further potential dimensions of health which began with the WHO
limitation to the medical model is its omission of a definition but have been subsequently expanded.
time dimension. Should we consider as equally The dimensions now include:
healthy two people in equal functional status, one Physical health. This is perhaps the most obvious
of whom is carrying a fatal gene that may lead to dimension of health, and is concerned with the
early death? mechanistic functioning of the body.
The holistic and wellness models have the advan- Mental health. Mental health refers to the ability
tage of allowing for mental as well as physical to think clearly and coherently. It can be distin-
health, and on broader issues of active participation guished from emotional and social health, although
in life. They also allow for more subtle discrimina- there is a close association between the three.
tion of people who succeed in living productive Emotional health. This means the ability to recog-
lives despite a physical impairment. The visually nise emotions such as fear, joy, grief and anger and
impaired or amputees, for example, may still be to express such emotions appropriately. Emotional
able to satisfy aspirations, be productive, happy (or affective) health also means coping with stress,
and so be viewed as healthy. The disadvantage is tension, depression and anxiety.
 Chapter 1 What is health? 7

Social health. Social health means the ability to capacities, not simply the absence of disease (WHO
make and maintain relationships with other people. 1984).
Spiritual health. For some people, spiritual health This is a rich view of health. It encompasses
might be connected with religious beliefs and prac- ideas of:
tices; for other people it might be associated with ● Personal growth and development (‘realise
personal creeds, principles of behaviour and ways aspirations’).
of achieving peace of mind and being at peace with ● Meeting personal basic needs (‘satisfy needs’).
oneself.
● The ability to adapt to environmental changes
Societal health. So far, health has been considered
(resilience to change and cope with the
at the level of the individual, but a person’s health
environment’).
is inextricably related to everything surrounding
● A means to an end, not an end in itself (a
that person. It is impossible to be healthy in a sick
society that does not provide the resources for basic resource for everyday life, not the objective of
physical and emotional needs. For example, people living).
obviously cannot be healthy if they cannot afford ● Not just absence of disease (a positive concept).
necessities like food, clothing and shelter, but ● A holistic concept (social and personal
neither can they be healthy in countries of extreme resources … physical capacities).
political oppression where basic human rights This notion of health has much to offer the health
are denied. Women cannot be healthy when promoter. It recognises that health is a dynamic
their contribution to society is undervalued, and state, that a person’s potential is different, and that
neither black nor white can be healthy in a racist each person’s health needs vary. Working for health
society where racism undermines human worth, is both an individual and a societal responsibility,
self-esteem and social relationships. Unemployed and involves empowering people to improve their
people cannot be healthy in a society that values quality of life.
only people in paid employment, and it is very This discussion of health as a concept is an
unlikely that anyone can be healthy if they live in important prerequisite to thinking about what
an area that lacks basic services and facilities such determines people’s health. Before moving on to a
as health care, transport and recreation. consideration of what affects health, it might be
The identification of these different aspects of useful to undertake Exercise 1.2 and to read Case
health is a useful exercise in raising awareness of studies 1.1 and 1.2 and answer the associated
the complexity and the holistic nature of health. But questions.
in practice it is obvious that dividing people’s
health into categories such as physical and mental
can impose artificial divisions and unhelpful distor- What Affects Health?
tions. Sexual health, for example, can cross all these
boundaries proving that the dimensions of health Being healthy is rarely, if ever, the result of chance
are interrelated. or luck. A state of health or ill health, however
Some writers have provided useful analyses of defined, is the result of a combination of factors
what health means from different disciplinary per- having a particular effect on a particular individual
spectives. Seedhouse (2001), for example, proposes at any one time. In order to work towards better
the idea of health as the foundation for achieving a health, we need to identify these influential factors.
person’s realistic potential. You can begin by identifying factors that influence
Similarly, when the WHO broadened their defi- your own health, using Exercise 1.3.
nition, as noted in the wellness model outlined Exercise 1.3 will have identified a huge range of
earlier in the chapter, they also identified key factors which affect health. They are likely to include
aspects of health. The conception of health is the genetic make-up, gender, family, religion, culture,
extent to which an individual or group is able to friends, income, advertising, social life, social class,
realise aspirations and satisfy needs, to change or race, age, employment status, working conditions,
cope with the environment, where health is seen health services, self-esteem, self-confidence, access
as a resource for everyday life, not the objective to leisure facilities and shops, housing, education,
of living; it is a positive concept emphasising national food policy, environmental pollution and
social and personal resources, as well as physical many more.
8 Promoting Health: A Practical Guide

EXERCISE 1.2 Dimensions of health EXERCISE 1.3 What affects your health?
1. Go back to your answers in Exercise 1.1 ‘What The aim of this radiating circle exercise is to identify
does being healthy mean to you?’ Tick if any of factors that affect your health. The exercise can be
the following dimensions of health are reflected in done:
the statements you ticked in Column 1: ■ individually
Physical ■ Emotional ■ ■ individually, followed by comparing results with
Mental Spiritual other people
■ ■
■ as a group, pooling your ideas about what
Social ■ Societal ■
influences your health.
Is any one of these dimensions more important to You are at the centre of the rings:
you than the others? How do they relate to each In the inner ring, write in factors that influence your
other? health and that are to do with yourself as an individual.
2. Has your idea of health changed since childhood? In the second ring, write in factors that influence
If so, how and why? How do you think your idea your health and that are to do with your immediate
of health may change as you grow older? social and physical environment.
3. If you have had professional training in health or In the outer ring, write in factors that influence your
a related area of work, what difference has this health and that are to do with your wider social,
made to your idea of health? physical or political environment.
4. What do you think being healthy may mean to
someone who: Outer ring
 has learning difficulties?
 has a permanent physical disability such as
deafness or paralysis? Second ring
 has an illness or infection for which there is
currently no known cure such as diabetes,
arthritis, HIV, schizophrenia? Inner ring
 lives in poverty?
5. Identify three or four key points you have learnt
from this exercise about your own ideas of being
healthy.
YOU

Health and Medicine

There has been much debate since the 1970s about
the relative importance of the many and varied
determinants of health. There have also been con-
cerns that medicine might have less effect on the How do these factors influence your health –
population’s overall health improvement than pro- positively or negatively?
moting lifestyle changes or social reforms, although Which factors do you think are the most important?
some have argued that these concerns are not Are there factors that you have not identified for
founded (see, for example, Bunker 2001). The yourself, but which may be important for other people?
National Health Service (NHS) has undoubtedly
(Burkitt 1982, reproduced with kind permission of Medical
evolved in the main as a treatment and care service
Education (International) Ltd.)
for people who are ill, not as the major means of
improving public health (Baggott 2004, Klein 2006
and Ham 2009 offer further discussion of the NHS
and healthcare policies).
Some people have claimed that the practice of
scientific medicine has, in fact, done considerable
harm. Examples are the side-effects of treatment,
complications that set in after surgery and depend-
 Chapter 1 What is health? 9

CASE STUDIES 1.1 AND 1.2 What shapes people’s health and health beliefs?
Case 1.1 Salma to have a second mastectomy and more
Salma had been widowed twice, and now believes chemotherapy. She is a primary school teacher and
that people are plotting against her. At the same has just returned to work part time. She loves her
time, she is in a desperate situation, living with her work and has very supportive colleagues. She was
four children in a small, crumbling, two-bedroomed divorced 2 years after the first mastectomy and now
terraced house. She has no money for repairs, and no lives alone with her daughter, Charlie. Anne has lots
husband to support her or help put things right. The of friends, a large extended family and a good social
rooms are poorly decorated and the emersion heater network. She feels healthy and is determined to
is broken so there is only cold water in the bathroom. overcome the cancer and has established a new diet
To have a bath, Salma has to heat water on the and exercise programme to help her stay healthy. Like
cooker downstairs and carry it up. The plumbing needs her parents, she wants to live to a very old age, and
repair, and there is no water in the cold water tap of looks forward to Charlie being settled in life and to
the washbasin. Salma sleeps with her daughter in one having grandchildren. She belongs to a cancer support
of the bedrooms and her three sons sleep in the other. group and is planning to undertake a half marathon
One of the downstairs rooms cannot be used because to raise money for a cancer charity. While Charlie
it needs replastering, and the floor boards are admires her mother and the way she is dealing with
dangerous in another. Salma applied for a repair grant her illness, she is worried that she may die of cancer
about a year and a half ago. They came and took soon. Charlie is in her final year of university and
pictures and didn’t do anything about it. She has also while she considers herself to be fit and healthy, since
applied for a council house, but she has been told it she became a student she smokes heavily, frequently
will take a long time. She feels there is nothing wrong binge drinks, and when she is very stressed will
with her health; just nerves. She feels like her life is occasionally use drugs. She often has casual and
being squeezed out of her. She worries about her sometimes unprotected sex when drunk. Her diet is
children. They cannot play outside or go to the park not good; she either skips meals or just eats take-
because the English children fight with them, and the away foods. She knows that her chances of getting
house is too small and dangerous to play in. breast cancer are higher because her mother has had
■ What affects the health of Salma and her children? it, so feels she should enjoy life to the full while she
■ What is Salma’s own view about her health? Why is young. She found her parents’ divorce very difficult
do you think she holds this view? and hasn’t seen her father in 5 years. She has been
■ What should be done to improve and promote the very depressed over the past 6 months but has
health of Salma and her children? (Adjusted from continued with her university degree because she
Commission for Racial Equality 1993.) knows her mother would be very upset if she
withdraws.
Case 1.2 Anne and Charlie ■ What affects the health of Anne and Charlie?
Anne is 57 years old and has cancer. She had it for ■ What are Anne’s and Charlie’s own views about
the first time 7 years ago, when a lump was their health? Why do you think they hold these
discovered when she went along to her first views?
mammography, and she had a mastectomy. Six ■ What could be done to improve and promote the
months ago another lump was discovered and she had health of Anne and Charlie?

ence on prescribed drugs. But more important, best, a treatment and care service for the ill and, at
perhaps, is that control over health and illness has worst, a means of undermining people’s compe-
been taken away from people themselves, who tence and confidence to improve their health
become dependent on doctors and medical drugs. reached a peak around 1980, led in part by the work
Aspects of life that are natural, such as pregnancy of Illich (1977), but they are still relevant today (see,
and childbirth, the menopause and ageing, have for example, Jackson 2001 and Meyer 2001). There
become medicalised and the responsibility for are moves to change this perception of the health
health has shifted from the lay public to the medical services and government policy is currently in place
profession. These arguments that medicine is, at to attempt to make the healthcare services fairer,
10 Promoting Health: A Practical Guide

more personalised, effective and safe (Department levels of trust and many networks for the exchange
of Health (DoH) 2007a). of information, ideas and practical help. Social
capital is produced when, for example, there are
neighbourhood schemes of child care and crime
The Wider Determinants of Health
prevention, community groups and social activities
The Black Report (Townsend & Davidson 1982) that engage a wide range of interests and people
showed that, for almost every kind of illness and (Li 2007).
disability in the UK, people in the upper socio­ Differences in health experience may not be due
economic groups had a greater chance of avoiding entirely to socioeconomic determinants. There are
illness and staying healthy than those in the lower important differences in rates of illness and death
socioeconomic groups. It also established the differ- between ethnic groups, which may be related to
ences in the risks to men and women, and varia- differences in income, education and living condi-
tions in the apparent health consequences of living tions, cultural factors or genetic make-up. There are
in different parts of the country. also differences associated with age, sex, occupa-
All this pointed to the fact that the major deter- tion and where people live (Wilkinson & Marmot
minants of health were socioeconomic conditions, 2003). Addressing the distribution of wealth in
geographical location and gender. Evidence from society, reducing the gap between rich and poor
the late 1990s (Acheson 1998) demonstrated that the and tackling socioeconomic disadvantage are
health gap was widening, so that while overall clearly political issues (DoH 2003), and the post-
population health may be improving, the rate of 2010 strategic review of health inequalities (the
improvement is not equal across all sections of Marmot Review) demonstrates the government’s
society. The gap in the health status between the continued commitment to reducing health
lower socioeconomic groups and the higher socio- inequalites.
economic groups continues to increase.
Work comparing data across different countries
has shown another slant on the issue of inequalities. Improving Health – Historical
It is not the richest societies that have the best Overview
health, but those that have the smallest income dif-
ferences between rich and poor. It is the relative A number of conclusions can be drawn from the
difference in income levels which is crucial. The discussion above. First, health is a complex concept,
reason seems to be that small income differences meaning different things to different people.
across society mean an egalitarian society that has Second, health status is linked with people’s ability
a strong community life and better quality of life in to reach their full potential. Finally, health is affected
terms of strong social networks, less social stress, by a wide range of factors, which may be broadly
higher self-esteem, less depression and anxiety and classified as:
more sense of control (Marmot 2005). All of this
● Lifestyle factors to do with individual health
adds up to better health.
In recent years the UK government has imple- behaviour.
mented a programme of action to tackle health ● Broader social, economic and environmental
inequalities (see DoH 2007b for a status report on factors such as whether people live in an
the strategies in place). At the time of writing the egalitarian society, what social support
government has also commissioned a post-2010 networks are available, and how they live in
strategic review of health inequalities (the Marmot terms of employment, income and housing.
Review; see References). It will be interesting to Early public health work in the first half of the
monitor whether the Marmot Review will repeat 20th century concentrated on structural reforms
the findings of earlier reports, or whether the review such as slum clearance, improved sanitation and
will show that the Programme for Action set in place clean air. Then in the 1950s and 1960s the focus
(DoH 2003) has been effective. shifted towards the need for changes in individual
One way of addressing health inequalities and health behaviour, for example, family planning,
inequities is by building social capital. Social capital venereal disease (the original term to describe
is the term used to describe investment in the social sexually transmitted infections), accident preven-
fabric of society, so that communities develop high tion, immunisation, cervical smear checks, weight
 Chapter 1 What is health? 11

control, alcohol consumption and smoking. This This regional strategy called for fundamental
emphasis on the lifestyle approach meant a con­ changes in the health policy of member countries,
centration of effort on health education, which was including a much higher priority for health promo-
reflected in government statements at the time tion and disease prevention. It called for not only
(see, for example, Department of Health and Social health services but all public sectors with a poten-
Security 1976). Over time, this emphasis has been tial impact on health to take positive steps to main-
heavily criticised because it distracts attention from tain and improve health. Specific regional targets
the social and economic determinants of health, were published; these have been subsequently
and tended to blame individuals for their own ill updated and the movement is now called Health
health. For example, people with heart disease 21 (WHO 1999a, b). The targets emphasised the
could be blamed for it because they were over- following HFA principles:
weight and smoked, but the reasons for being over-
● Reducing inequalities in health.
weight and smoking, what Marmot (2005) refers
● Positive health through health promotion and
to as the causes of the causes, were ignored. Reasons
disease prevention.
may have included lack of education, no help avail-
able to stop smoking, eating and smoking used as ● Community participation.
a way of coping with stresses such as poor housing ● Cooperation between health authorities, local
or unemployment, lack of availability of cheap authorities and others with an impact on
nutritious foods, and so on. This blaming people health.
for their health behaviour became known as victim- ● A focus on primary health care as the main
blaming (see Dougherty (1993) and Caraher (1995) basis of the healthcare system.
for early discussions of victim-blaming). In the The Health for All targets for Europe, which
1980s a broader approach was used in conjunction European governments and the WHO aimed to
with what was called the new public health move- reach by 2000, were reviewed and evaluated at the
ment (WHO 1986). It encompassed health educa- end of the century (http://www.euro.who.int).
tion but also political and social action to address Progress had been made on many fronts, but targets
issues such as poverty, employment, discrimina- had not been reached, mainly because of political,
tion and the environment in which people live. social and economic difficulties.
It also, importantly, focused on the grass-roots Health 21 sets out 21 targets for the European
involvement of people in shaping their own health region. The targets cover a wide range, including
destiny. reducing health inequalities. Target 2 states: ‘By the
See Chapter 4 for information on people and year 2020, the health gap between socioeconomic
organisations working to improve public health. groups within countries should be reduced by at
least one fourth in all Member States, by substan-
tially improving the level of health of disadvan-
International Initiatives for taged groups’ (WHO 1999b). Other Health 21 targets
Improving Health cover better health for children and older people;
reducing communicable and chronic diseases, inju-
More is said about the role of the WHO and other ries and harm from alcohol, drugs and tobacco;
international organisations in Chapter 4. developing better health care, policies and strate-
gies for health; and partnership working.
The WHO took a leading role in the evolution of
A major milestone for health promotion was the
health promotion in the 1980s and 1990s. It stated
publication in 1986 of the Ottawa Charter, launched
in 1978 that the main target of governments in the
at the first WHO international conference on
coming decades should be the attainment of all
health promotion held in Ottawa, Canada (WHO
citizens of the world by the year 2000 of a level of
1986). This identified five key themes for health
health that will permit them to lead a socially and
promotion:
economically productive life (WHO 1978). This was
the beginning of what came to be known as the 1. Building a healthy public policy.
Health for All (HFA) movement. It led to the devel- 2. Creating supportive environments.
opment of a strategy for the WHO European Region 3. Developing personal skills through information
in 1980 (WHO 1985). and education in health and life skills.
12 Promoting Health: A Practical Guide

4. Strengthening community action. health improvement. The first was The Health of the
5. Reorienting health services towards prevention Nation in England (DoH 1992), and comparable
and health promotion. strategies for Wales, Scotland and Northern Ireland.
(See Scriven & Speller (2007) for an overview of the These were the first national strategies to focus on
global influence of Ottawa.) health and health gain rather than illness and health
The Jakarta declaration in 1997 (WHO 1997) re­­ services.
iterated the importance of the Ottawa Charter prin- The most recent of these strategies are:
ciples and added priorities for health promotion ● 2001: the National Assembly for Wales (NAW)
in the 21st century: published Improving Health in Wales: a
● Promote social responsibility for health. Summary Plan for the NHS with its Partners
● Increase investment for health development. (NAW 2001a) and an action plan Promoting
● Expand partnerships for health promotion. Health and Wellbeing: Implementing the
● Increase community capacity and empower the
National Health Promotion Strategy (NAW
individual. 2001b).
● 2002: in Northern Ireland the Department of
● Secure an infrastructure for health promotion.
Health and Social Services and Public Safety
The Bangkok Charter for Health in a Globalized World (DHSSPS) published Investing for Health: a
is the most recent WHO declaration (WHO 2005). Public Health Strategy for Northern Ireland
The Charter builds on Ottawa by asserting that (DHSSPS 2002).
progress towards a healthier world requires strong
● 2003: the Scottish Office (SO) published
political action, broad participation and sustained
Improving Health in Scotland: the Challenge
advocacy.
(SO 2003).
The call is to ensure that health promotion’s
● 2004: in England the Department of Health
established repertoire of proven effective strategies
will need to be fully utilised, with all sectors and published Choosing Health: Making Healthy
settings acting to: Choices Easier (DoH 2004).
● advocate for health based on human rights and A further significant development was that in
solidarity 2001 the Department of Health published national
● invest in sustainable policies, actions and targets to reduce inequalities in England, and re­­
infrastructure to address the determinants of affirmed these in 2007 as part of the spending
health review. This welcome emphasis on reducing ine-
● build capacity for policy development, qualities ensures that work to improve the health
leadership, health promotion practice, knowledge of the public will have inequalities in health at its
transfer and research, and health literacy core, at both local and national levels. The targets
● regulate and legislate to ensure a high level of are as follows:
protection from harm and enable equal ● Starting with children under 1 year, by 2010 to
opportunity for health and wellbeing for all reduce by at least 10% the gap in mortality
people between routine and manual groups and the
● partner and build alliances with public, population as a whole.
private, nongovernmental and international ● Starting with local authorities, by 2010 to
organizations and civil society to create reduce by at least 10% the gap in life
sustainable actions. expectancy between the fifth of areas with the
worst health and deprivation indicators (the
National Initiatives Spearhead Group) and the population as a
whole (http://www.dh.gov.uk).
See Chapter 7, section on national health strategies, for
Also in 2001, a long-awaited report was produced
more about national strategies for health and how they
by the Chief Medical Officer, setting out the role for
are implemented.
a stronger public health function and building
An important development for the UK in the early on targets set in national health strategies (DoH
1990s was the advent of national strategies for 2001). The report identified major themes relevant
 Chapter 1 What is health? 13

to achieving a stronger public health function, economic groups in the UK (DoH 2007b, 2009).
including: Health promoters in the UK are still faced with
● a wider understanding of health entrenched inequality in health status, and huge
problems of poverty, unemployment and home-
● a better and more coordinated public health
lessness (Marmot 2005). This raises questions about
function
the distribution of wealth in society and emphasises
● partnership working
that health is a political issue.
● community development and public
involvement
● an increased and more capable public health PRACTICE POINTS
workforce ■ Health and being healthy mean different things to
● increased health protection. different people, and you need to explore and
understand what they mean to you and to your
clients.
Where Are We Now? ■ A wide range of factors at many levels influence
and determine people’s health.
It is clear from the above that there is a broad under- ■ There are wide inequalities in the health status of
standing of the wider determinants of people’s people from different social classes, ethnic groups,
health, and there are international and national age groups, sexes and people who live in different
health strategies which are reviewed and revised on geographical locations.
an ongoing basis. There is a stronger national and ■ Improving people’s health means addressing the
local emphasis on prevention, health improvement social, environmental and economic factors that
and reducing inequalities, with health promotion affect their health, as well as individual health
playing a bigger part in the role of all the health and behaviour and lifestyle.
social welfare professions. Health issues feature ■ International and national strategies and
more in public policy debate at both central and movements have emerged to tackle the lifestyle,
local government and in the health service. socioeconomic and environmental determinants of
But as yet these positive developments have health, and to reduce inequalities in health.
failed to narrow the health gap between socio­

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Health 21: health for all in the 21st WHO, Geneva. http://www.who. Publichealth/Healthinequalities/
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World Health Organization 2005 The ca/epi5251/Index_notes/
Bangkok charter for health Definitions%20of%20health.htm
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 17

Chapter 2
What is health promotion?

Summary
Chapter Contents
This chapter starts with a discussion of the definitions
Defining health promotion 17 of health promotion, and the related terms health
gain, health improvement, health development, health
Health gain, health improvement and health
education and social marketing. This is followed by
development 18
an examination of the position of health promotion
Health education, health promotion and social within the multidisciplinary public health movement.
marketing 18 An outline of the scope of health promotion work is
offered, with frameworks for activities for promoting
Multidisciplinary public health 19
health. Broad areas of practice covered by professional
Involvement in public health 20 health promoters and the core competencies needed
are set out with an outline of the framework for
The scope of health promotion 20
national occupational standards. Exercises are included
A framework for health promotion activities 24 to help you explore the range of health promotion
Broad areas of competencies important to health activities and the extent of your own health
promotion practice 25 promotion work.

Occupational standards in health promotion 26

Defining Health Promotion

Health promotion is about raising the health status

of individuals and communities. Promotion in the
health context means improving, advancing, sup-
porting, encouraging and placing health higher on
personal and public agendas.
Given that major socioeconomic determinants of
health are often outside individual or even collec-
tive control, a fundamental aspect of health promo-
tion is that it aims to empower people to have more
control over aspects of their lives that affect their
health.
These twin elements of improving health and
having more control over it are fundamental to the
aims and processes of health promotion. The World
18 Promoting Health: A Practical Guide

Health Organization (WHO) definition of health

promotion as it appears in the Ottawa Charter has Health needs
been widely adopted and neatly encompasses this: assessment
‘Health promotion is the process of enabling people (Where are we now?)
to increase control over, and to improve, their
health’ (WHO 1986).

Decide priorities
Health Gain, Health Improvement Evaluation
and set targets
and Health Development (How well are we doing?
How far have we got?) (Where do we want
to get to?)
Health development, health improvement and
health gain are terms that are also employed
when discussing the process of working to improve
people’s health. Health development is defined as Make agreements
the process of continuous, progressive improve- and commission health
ment of health status of individuals and groups in services and programmes
a population (Nutbeam 1998). The Jakarta Declara- (Specifying how we will
get there)
tion (WHO 1997) describes health promotion as an
essential element of health development. Health
Fig. 2.1 The health gain cycle.
improvement is frequently used by national
health agencies. For example, there is a health
improvement section on the Department of
Health (DoH) website (http://www.dh.gov.uk)
and NHS Scotland calls itself Scotland’s health smoking has been effective when so many influ-
improvement agency (http://www.healthscotland. ences can affect smoking habits?
com). A research study undertaken by Abbott An intervention means a planned activity
(2002), however, found that people’s understand- designed to improve health. It could be treatment,
ing of health improvement varied and ranged from a care service or a health promotion activity.
explaining the term primarily as a government The role of health promoters in assessing health
strategy – as a set of activities for the NHS – or in needs, deciding on priorities, setting objectives and
terms of the overarching purpose of health improve- targets, allocating resources, and monitoring and
ment. One definition sees health improvement reviewing outcomes can be seen as a health gain
as covering a wide range of activity, principally cycle (Fig. 2.1). Health gain is a useful concept. It
focused on improving the health and wellbeing of focuses attention on health outcomes and on how
individuals and communities (so much like health different choices or priorities can be compared by
promotion) (http://www.suffolkcoastal.gov.uk). considering the extent to which they contribute to
The term health gain emerged in policy docu- health gains for individuals or groups.
ments in the late 1980s (for example, Welsh Health
Planning Forum 1989). One useful early definition
said health gain was a measurable improvement in Health Education, Health
health status, in an individual or population, attrib- Promotion and Social Marketing
utable to earlier intervention (Nutbeam 1998).
Measurable means that it should be possible to The WHO (1998) defined health education as the
put a value, usually a numerical value, onto health consciously constructed opportunities for learning
status, in order to demonstrate that a change has involving some form of communication designed
occurred. to improve health literacy, including improving
Attributable means proving that the change in knowledge, and developing life skills which are
health status is the result of the intervention. This conducive to individual and community health (see
can be difficult. How will you be certain, for Smith et al 2006 for updates on the WHO glossary
example, that a specific programme to reduce of health promotion terms). In the 1970s the range
 Chapter 2 What is health promotion? 19

of activities undertaken in the pursuit of better organised efforts of society. The Faculty of Public
health began to diverge from health education Health (FPH) also uses this definition but offers
(Scriven 2005). There was also criticism that the guidelines specifying that public health:
health education approach was too narrow, focused ● Is population based.
too much on individual lifestyle and could become ● Emphasises collective responsibility for health,
victim-blaming (see Ch. 1, Improving Health – its protection and disease prevention.
Historical Overview) and increasingly work was
● Recognises the key role of the state, linked to a
being undertaken on wider issues such as political
concern for the underlying socioeconomic and
action to change public policies. Such activities
wider determinants of health, as well as
went beyond the scope of traditional health
disease.
education.
● Emphasises partnerships with all those who
Health promotion as a term was used for the
first time in the mid 1970s (Lalonde 1974) and contribute to the health of the population
quickly became an umbrella term for a wide range (http://www.fphm.org.uk).
of strategies designed to tackle the wider determi- Three spheres of public health have been outlined
nants of health. There is no clear, widely adopted by Griffiths et al (2005):
consensus of what is meant by health promotion
(see Scriven 2005 for a detailed discussion of Health improvement
the development and use of the term). Some defini- ● Inequalities
tions focus on activities, others on values and prin- ● Education
ciples. The WHO (1986) definition defines health ● Housing
promotion as a process but implies an aim (enabling ● Employment
people to increase control over, and improve, ● Family/community
their health) with a clear philosophical basis of ● Lifestyles
self-empowerment.
● Surveillance and monitoring of specific diseases
Recently in the UK, health-related social market-
and risk factors.
ing has emerged as a prominent health promoting
strategy to achieve and sustain behaviour goals on
Improving services
a range of social issues. There are a number of defi-
● Clinical effectiveness
nitions of social marketing, but the description most
generally in use is the systematic application of ● Efficiency
marketing, alongside other concepts and tech- ● Service planning
niques, to achieve specific behavioural goals, for a ● Audit and evaluation
social good and to improve health and reduce ine- ● Clinical governance
qualities (French & Blair-Stevens 2005). The exact ● Equity.
relationship between social marketing and health
promotion is currently being debated, so there is no Health protection
consensus on whether social marketing comes ● Infectious diseases
under the health promotion umbrella of approaches ● Chemicals and poisons
to health gain.
● Radiation
● Emergency response
Multidisciplinary Public Health ● Environmental health hazards.
It is clear from these definitions and explanations
In the last decade, national and local policy has that public health requires a wide range of comp­
focused on the development of multidisciplinary etencies (Evans & Dowling 2002), that it is a multi-
public health (see Berridge 2007 for a critique and disciplinary activity involving people from many
overview of these developments). Public health professions and backgrounds (DoH 2001, Coen &
work has been defined by Acheson (DoH 1998) as Wills 2007) and that health promotion activities
the science and art of preventing disease, pro­ overlap with and are an integral part of the UK
longing life and promoting health through the public health function (DoH 2005).
20 Promoting Health: A Practical Guide

Involvement in Public Health The Scope of Health Promotion

See also Chapter 1, section on national initiatives, for The questions in Exercise 2.1 give examples of the
more about this report. wide range of activities that may be classified as
health promotion. Answering ‘yes’ to each one indi-
There are three levels of involvement in public
cates a broad view of what may be included: mass
health (DoH 2001):
media advertising, campaigning on health issues,
1. Teachers, social workers, voluntary sector staff patient education, self-help, environmental safety
and health workers all have a role in health measures, public policy issues, health education,
improvement. They need to adopt a public preventive and curative medical procedures, codes
health mind set and appreciate how their work of practice on health issues, health-enhancing facili-
can make a difference to health and wellbeing, ties in local communities, workplace health policies
and where more specialist support can be and social education for young people. Answering
obtained locally. ‘no’ indicates that you identify criteria that you
2. A smaller number of hands-on public health believe exclude these activities from the realms of
professionals, such as health visitors and health promotion. For example, you may have said
environmental health officers, who spend a ‘no’ to Item 2 because increasing tobacco taxation
major part, or all, of their time in public health would place a heavier burden on smokers in poor
practice working with communities and groups. financial circumstances, thus putting their health
3. A still smaller group of public health specialists even more at risk.
from medical and other professional Attempts to provide frameworks and models
backgrounds, who work at a senior level with for classifying activities have helped to clarify the
responsibility to manage strategic change and scope of health promotion (see Naidoo & Wills 2000
lead public health initiatives. This group for an overview). Drawing on these, Fig. 2.2 identi-
includes health promotion specialists and fies the activities that contribute to health gain and
medically qualified public health doctors. maps out all those activities which aim to improve
people’s health. There are two sets of activities,
The roles of professionals who contribute to health those about providing services for people who are
promotion work are discussed in Chapter 4. ill or who have disabilities, and positive health

EXERCISE 2.1 Exploring the scope of health promotion

Consider each of the following activities and decide whether you think each is, or is not, health promotion:
Yes No
1. Using TV advertisements to encourage people to be more physically active.  
2. Campaigning for increased tax on tobacco.  
3. Explaining to patients how to carry out their doctor’s advice.  
4. Setting up a self-help group for people who have been sexually abused as children.  
5. Providing schools with a crossing patrol to help children across the road outside schools.  
6. Raising awareness of how poverty affects health.  
7. Giving people information about the way their bodies work.  
8. Immunising children against infectious diseases such as measles.  
9. Protesting about a breach in the voluntary code of practice for alcohol advertising.  
10. Running low-cost gentle exercise classes for older people at local leisure centres.  
11. Providing healthier menu choices at workplace canteens.  
12. Teaching a programme of personal and social education in a secondary school.  
13. Providing support to people with learning disabilities living in the community.  
14. Using social marketing tools to ensure behavioural change in a group of smokers.  
What were your reasons for saying ‘yes’ or ‘no’? Can you identify the criteria you are using for deciding whether an
activity is ‘health promotion’?
 Chapter 2 What is health promotion? 21

Personal Health
social services care services

ILLNESS AND
DISABILITY
SERVICES

HEALT H G A IIN
N
Health
Preventive
education
health services
programmes

Social Community-based
marketing POSITIVE work
HEALTH
ACTIVITIES
Economic
Organisational
and regulatory
development
activities

Environmental Healthy
health measures public policies

Fig. 2.2 Activities for health gain.

activities, which are about personal, social and Healthcare services. This includes the major work
environmental changes aiming to prevent ill health of the health services: treatment, cure and care in
and develop healthier living conditions and life- primary care and hospital settings.
styles. These two sets of activities overlap, because An important question when considering the
they both contribute to health gain, and they are boundaries of service provision by health promot-
often closely related in practice. Ten categories of ers is: ‘If all illness and disability services improve
activities are identified, comprising two illness and health and produce varying amounts of health gain,
disability services and eight types of positive health are they all called health promotion?’ For example,
activities. is taking out someone’s appendix or placing a child
in a foster home health promotion?
It is helpful to go back to the WHO (1986) defini-
Illness and Disability Services
tion of health promotion, about enabling people to
Personal social services. This includes all those increase control over and improve their health.
social services aimed at addressing the needs of sick Things that need to be done to people (like taking
people and people with disabilities or disadvan- out their appendix or placing them in foster homes)
tages whose health (in its widest sense) is improved are excluded from this definition, so are generally
by those services. This includes, for example, com- not considered to be health promotion activities
munity care of mentally ill people and home help (although they are health gain activities). But those
services for the elderly. aspects of care and treatment that are about
22 Promoting Health: A Practical Guide

enabling people to take control over their health secondary health education, educating patients
and improve it (such as educating patients in the about their condition and what to do about it.
skills of self-care, or educating foster parents in the Restoring good health may involve the patient in
skills of parenting) are legitimate areas of health changing behaviour (such as stopping smoking) or
promotion. So is creating a health promoting envi- in complying with a therapeutic regime and, pos-
ronment by, for example, modifying a home to sibly, learning about self-care and self-help. Clearly,
make it suitable for a person with disabilities or health education of the patient is of great impor-
providing affordable housing for homeless people tance if treatment and therapy are to be effective
with health problems. and illness is not to recur.
Tertiary health education. There are, of course,
many patients whose ill health has not been, or
Positive Health Activities
could not be, prevented and who cannot be com-
pletely cured. There are also people with perma-
Health education programmes nent disabilities. Tertiary health education is
These are planned opportunities for people to learn concerned with educating patients and their carers
about health, and to undertake voluntary changes about how to make the most of the remaining
in their behaviour. Such programmes may include potential for healthy living, and how to avoid
providing information, exploring values and atti- unnecessary hardships, restrictions and complica-
tudes, making health decisions and acquiring skills tions. Rehabilitation programmes contain a consid-
to enable behaviour change to take place. They erable amount of tertiary health education with a
involve developing self-esteem and self-empower- focus on improving quality of life.
ment so that people are enabled to take action about Quantenary health education. This concentrates on
their health. This can happen on a personal one-to- facilitating optimal states of empowerment and
one level such as health visitor/client, teacher/ emotional, social and physical wellbeing during a
pupil, or in a group such as a smoking cessation terminal stage (see Hancock 2001, Scriven 2005).
group or exercise class, or reach large population It is not always easy to see where people fit into
groups through the mass media, health fairs or this primary, secondary or tertiary framework
exhibitions. because a person’s state of health is open to inter-
pretation. For example, is educating an overweight
See Chapters 10–14 for detailed information on carrying
person who appears to be perfectly well, despite
out these health promotion activities.
being overweight, primary or secondary health
Health education programmes may also be a education?
part of healthcare and personal social services, and
because of this it is useful to understand the con-
cepts of primary, secondary and tertiary health
Social marketing
education. The National Social Marketing Centre (NSMC)
Primary health education. This would reflect identifies the primary aim of health-related social
McKinley’s (1979) vision of upstream, preventative marketing as the achievement of a social good
activity. It is directed at healthy people, and aims to (rather than commercial benefit) in terms of
prevent ill health arising. Most health education for specific, achievable and manageable behaviour
children and young people falls into this category, goals, relevant to improving health and reducing
dealing with such topics as sexual health, nutrition health inequalities. Social marketing is a systematic
and social skills and personal relationships, and process using a range of marketing techniques and
aiming to build up a positive sense of self-worth in approaches (a marketing mix) phased to address
children. Primary health education is concerned not short-, medium- and long-term issues. The follow-
merely with helping to prevent illness but with ing six features and concepts are pertinent to under-
positive wellbeing. standing social marketing:
Secondary health education. There is also often a Customer or consumer orientation. A strong cus-
major role for health education when people are ill. tomer orientation with importance attached to
It may be possible to prevent ill health moving to a understanding where the customer is starting from,
chronic or irreversible stage, and to restore people their knowledge, attitudes and beliefs, along with
to their former state of health. This is known as the social context in which they live and work.
 Chapter 2 What is health promotion? 23

Behaviour and behavioural goals. Clear focus on to examine in more detail the links between social
understanding existing behaviour and key influ- marketing and health promotion, see NSMC (2008).
ences upon it, alongside developing clear behav-
ioural goals. These can be divided into actionable
and measurable steps or stages, phased over time.
Preventive health services
Intervention mix and marketing mix. Using a mix of These include medical services that aim to prevent
different interventions or methods to achieve a par- ill health, such as immunisation, family planning
ticular behavioural goal. When used at the strategic and personal health checks, as well as wider pre-
level this is commonly referred to as the interven- ventive health services such as child protection
tion mix, and when used operationally it is described services for children at risk of abuse.
as the marketing mix.
Audience segmentation. Clarity of audience focus
using audience segmentation to target effectively.
Community-based work
Exchange. Use of the exchange concept, under- This is a bottom-up approach to health promotion,
standing what is being expected of people, and the working with and for people, involving communi-
real cost to them. ties in health work such as local campaigns for
Competition. This means understanding factors better facilities. It includes community develop-
that impact on people and that compete for their ment, which is essentially about communities iden-
attention and time (adjusted from http://www. tifying their own health needs and taking action to
nsmcentre.org.uk). address them. The sort of activities that may result
Social marketing uses the total process planning could include forming self-help and pressure
model summarised in Fig. 2.3. The front end scoping groups, and developing local health-enhancing
stage drives the whole process. The primary concern facilities and services.
is establishing clear actionable and measurable
See Chapter 15, Working with communities.
behaviour goals to ensure focused development
across the rest of the process. The ultimate effective-
ness and success of social marketing rests on Organisational development
whether it is possible to demonstrate direct impact
This is about developing and implementing policies
on behaviour. It is this feature that sets it apart
within organisations to promote the health of staff
from other communication or awareness raising
and customers. Examples include implementing
approaches, such as health education, where the
policies on equal opportunities, providing healthy
main focus is on imparting information and ena-
food choices at places of work and working with
bling people to understand and use it. The informa-
commercial organisations to develop and promote
tion on social marketing above has been adjusted
healthier products.
from the NSMC website (http://www.nsmcentre.
org.uk). For more details on how to engage in See Chapter 16, Influencing and implementing policy.
health-related social marketing, see Macdowall
et al (2006) and NSMC (2007). To explore the effec-
Healthy public policies
tiveness of social marketing as an approach, see
McDermott et al (2005) and Stead et al (2007), and Developing and implementing healthy public poli-
cies involves statutory and voluntary agencies, pro-
fessionals and the public working together to
develop changes in the conditions of living. It is
about seeing the implications for health in policies
about, for example, equal opportunities, housing,
Scope Develop Implement Evaluate Follow-up
employment, transport and leisure. Good public
transport, for example, would improve health by
reducing the number of cars on the road, decreasing
pollution, using less fuel and reducing the stress of
the daily grind of travelling for commuters. It could
Fig. 2.3 Social marketing uses a total process planning also reduce isolation for those who do not own cars
model. (NSMC and Consumer Focus 2007. Reproduced with permission). and enable people to have access to shopping and
24 Promoting Health: A Practical Guide

leisure facilities, all measures that improve well­ in Fig. 2.4. The first is that activities do not always
being (See Scriven 2007 for a detailed overview of fall neatly into categories. For example, would a
healthy public policies). health visitor who was supporting a local women’s
health group be engaged in a health education pro-
See Chapter 16, Influencing and implementing policy.
gramme because they provided health information
to the group and set up stress management ses-
Environmental health measures sions, or in community-based work because some
Environmental health is about making the physical members of the group had got together to lobby
environment conducive to health, whether at home, their local health services for better sexual health
at work or in public places. It includes public health advice clinics for young people?
measures such as ensuring clean food and water Obviously areas of activity overlap, but this is
and controlling traffic and other pollution. not important. What is important is to appreciate
the range of activities encompassed by health pro-
motion, and the many ways in which you can con-
Economic and regulatory activities tribute to health improvements.
These are political and educational activities The second point about using this framework
directed at politicians, policy makers and planners, is to note that it reflects planned, deliberate activi-
involving lobbying for and implementing legisla- ties, and it is important to recognise that a great
tive changes such as food labelling regulations, deal of health promotion happens informally and
pressing for voluntary codes of practice such as incidentally. For example, portrayal of damage
those relating to alcohol advertising or advocating caused by excessive drinking on television soaps
financial measures such as increases in tobacco and an advertising campaign to promote whole-
taxation. wheat breakfast cereals are all health promotion
activities which are not likely to be planned with
specific health promotion aims in mind. They may,
A Framework for Health however, be significant influences for change.
Promotion Activities
See Chapter 11, section on mass media.

There are two important points to make about the Exercise 2.2 is designed to help you to identify
use of the framework of health promotion activities your own contribution to health promotion.

Health education Preventive

(primary, secondary health services
and tertiary

Social Community-based
marketing work
AREAS OF
HEALTH PROMOTION
ACTIVITIES
Economic
Organisational
and regulatory
development
activities

Environmental Healthy
health measures public policies

Fig. 2.4 A framework for health promotion activities.

 Chapter 2 What is health promotion? 25

high level of competence is needed in one-to-one

EXERCISE 2.2 Identifying your health promotion
work communication and in working with groups in
various ways, both formal and informal.
Look at Fig. 2.4 again, which identifies eight major areas Effective communication is an educational com-
of health promotion activity. By each of the eight petence, but health promoters also need to under-
headings, note down any parts of your work you think stand how people receive information and learn.
come into that category. If you are not sure what each For example, patient education requires communi-
category includes, look back at the explanations. Then cation and educational competencies.
think about each category again, and consider whether
there is scope for developing your work within each
category. Marketing and publicising
Marketing and publicising are addressed in Chapter 11.

This requires competence in, for example, market-

ing and advertising, using local radio and getting
Broad Areas of Competencies local press coverage of health issues. It may be used
Important to Health when undertaking any health promotion activities
Promotion Practice that would benefit from wider publicity.
In order to engage in the activities outlined in the
framework in Fig. 2.4, health promoters require a Facilitating, networking,
range of competencies. There are two aspects of partnership working
work to consider. One is the technical/specialist
This means enabling others to promote their own
aspect such as immunising a child, taking a cervical
and other people’s health, using various means
smear test, recording blood pressure or undertak-
such as sharing skills and information and building
ing microbiological tests for food hygiene purposes.
up confidence and trust. These competencies are
All of these are the subject of specialist training, and
particularly important when working with commu-
outside the scope of this book.
nities. They are also vital for working with other
The other aspect of your work is about working
agencies and forming partnerships for health that
with people to promote health in many different
cross barriers of organisations and disciplines.
situations with a variety of different aims. To do
this, health promoters need to have knowledge of Facilitating, networking and partnership working are
particular methods and acquire specialist compe- addressed in Chapters 9, 13 and 15.
tencies in the following areas:
Influencing policy and practice
Managing, planning and evaluating Health promoters are in the business of influencing
All these are addressed in Part 2: Planning and policies and practices that affect health. These can
managing for effective practice, Chapters 5–9. be at any level, from national (such as policies set
by government or political parties about, for
Managing resources for health promotion, includ-
example, housing, transport and future directions
ing money, materials, oneself and other people, is
for the NHS) to the level of day-to-day work of a
crucial. Systematic planning is needed for effective
health promoter (such as what sort of health pro-
and efficient health promotion. All health promo-
motion programmes will be run in a GP practice, or
tion work also requires evaluation, and different
what resources will be devoted to specific health
methods are appropriate for different approaches.
promotion activities in an environmental health
department).
Communicating and educating Influencing policy and practice is addressed in Chapter 16.
Communication and educating are addressed in Chapters
In order to influence policy and practice, you
8–14.
need to understand how power is distributed and
Health promotion is about people, so com­petence exercised between people at any level, from a group
in communication is essential and fundamental. A of colleagues to those in positions of great authority
26 Promoting Health: A Practical Guide

or influence. You need to be able to use that know­ competencies for health promotion. Currently in
ledge to affect decisions. This includes working the UK competencies set out in the form of occupa-
with statutory, voluntary and commercial organisa- tional standards are available for specialists and
tions to influence them to develop health promot- practitioners in public health (Skills for Health
ing policies for their staff and to produce health 2007). There is currently no agreed route through
enhancing products and services. It also includes these standards for health promotion specialists or
working for healthy public policies and economic practitioners.
and regulatory changes requiring lobbying and At an international level, the Galway Con­­
taking political action. sensus Statement (http://www.sophe.org; see also
It is unrealistic to expect all health promoters to Morales et al 2009) sets out eight domains of core
be highly competent in all aspects of health promo- competency in health promotion. They are: catalys-
tion. Practice nurses, for example, will work pre- ing change, leadership, assessment, planning,
dominantly in health education and preventive implementation, evaluation, advocacy and partner-
health services, needing a high level of competence ships. At the time of writing there is broad consulta-
in communication and education. However, they tion on the consensus statement, so it will be
also needs other competencies in order to plan and interesting to monitor the development of both UK
evaluate their work, market health promotion pro- and international health promotion competency
grammes to their patients, facilitate change in their statements over the coming years.
patients and be able to refer them to a network of The standards developed for specialist practice
helpful contacts. They will also need to be able to in public health set out in Box 2.1 are applicable (at
influence the development of health promotion least in part) to health promotion. It is useful to
policy in their practice. examine these standards and to think about the
areas of health promotion work you are involved in
and which standards are important for your work.
Occupational Standards in It is also important to recognise the areas you do
Health Promotion not use in your work and to think about the implica-
tions for working collaboratively with other pro­
At the time of writing there are a number of differ- fessionals. Exercise 2.3 is designed to encourage
ent initiatives taking place in the UK and in Europe you to think about your health promotion work and
that will result in a much clearer set of core how it contributes to the wider public health

BOX 2.1 Overview of the national standards for public health (Skills for Health 2007)
Area 1: Surveillance and assessment of the 6. Collect, structure and analyse data on the health
population’s health and wellbeing – see Chapter 6 and wellbeing and related needs for a defined
population.
1. Collect and form data and information about health
7. Undertake surveillance and assessment of the
and wellbeing and/or stressors to health and
population’s health and wellbeing.
wellbeing.
2. Obtain and link data and information about health
Area 2: Promoting and protecting the population’s
and wellbeing and/or stressors to health and
health and wellbeing – see Chapters 5–7 and 16
wellbeing.
3. Analyse and interpret data and information about 1. Communicate with individuals, groups and
health and wellbeing and/or stressors to health and communities about promoting their health and
wellbeing. wellbeing.
4. Communicate and disseminate data and information 2. Encourage behavioural change in people and
about health and wellbeing and/or stressors to agencies to promote health and wellbeing.
health and wellbeing. 3. Work in partnership with others to promote health
5. Facilitate others’ collection, analysis, interpretation, and wellbeing and reduce risks within settings.
communication and use of data and information 4. Work in partnership with others to prevent the
about health and wellbeing and/or stressors to onset of adverse effects on health and wellbeing in
health and wellbeing. populations.

Continued
 Chapter 2 What is health promotion? 27

BOX 2.1 Overview of the national standards for public health (Skills for Health 2007) – cont’d
5. Work in partnership with others to contact, assess Area 6: Policy and strategy development and
and support individuals in populations who are at implementation to improve health and wellbeing
risk from identified hazards to health and wellbeing. – see Chapter 16
6. Work in partnership with others to protect the
1. Work in partnership with others to plan, implement,
public’s health and wellbeing from specific risks.
monitor and review strategies to improve health
7. Promote and protect the population’s health and
and wellbeing.
wellbeing.
2. Work in partnership with others to assess the
Area 3: Developing quality and risk management impact of policies and strategies on health and
within an evaluative culture – see Chapter 7 wellbeing.
3. Work in partnership with others to develop policies
1. Develop one’s own knowledge and practice.
to improve health and wellbeing.
2. Contribute to the development of the knowledge
4. Appraise policies and recommend changes to
and practice of others.
improve health and wellbeing.
3. Support and challenge workers on specific aspects
5. Improve health and wellbeing through policy and
of their practice.
strategy development and implementation.
4. Manage the performance of teams and individuals.
5. Contribute to improvements at work.
Area 7: Working with and for communities to
6. Develop quality and risk management within an
improve health and wellbeing – see Chapter 15
evaluative culture.
1. Facilitate the development of people and learning in
Area 4: Collaborative working for health and communities.
wellbeing – see Chapters 4 and 9–14 2. Create opportunities for learning from practice and
1. Build relationships within and with communities experience.
and organisations. 3. Support communities to plan and take collective
2. Develop, sustain and evaluate collaborative work action.
with others. 4. Facilitate the development of community groups/
3. Represent one’s own agency at other agencies’ networks.
meetings. 5. Enable people to address issues related to health
4. Work in partnership with communities to improve and wellbeing.
their health and wellbeing. 6. Enable people to improve others’ health and
5. Enable the views of groups and communities to be wellbeing.
heard through advocating on their behalf. 7. Work with individuals and others to minimise the
6. Provide information and advice to the media about effects of specific health conditions.
health and wellbeing and related issues. 8. Improve health and wellbeing through working with
7. Improve health and wellbeing through working and for communities.
collaboratively.
Area 8: Strategic leadership for health and
Area 5: Developing health programmes and services wellbeing – see Chapters 8 and 13
and reducing inequalities – see Chapters 5–8
1. Use leadership skills to improve health and
1. Work in partnership with others to plan, implement wellbeing.
and review programmes and projects to improve 2. Promote the value of, and need for, health and
health and wellbeing. wellbeing.
2. Manage change in organisational activities. 3. Lead the work of teams and individuals to achieve
3. Develop people’s skills and roles within community objectives.
groups/networks. 4. Design learning programmes.
4. Assess, negotiate and secure sources of funding. 5. Enable learning through presentations.
5. Develop health programmes and services and reduce 6. Evaluate and improve learning and development
inequalities. programmes.

Continued
28 Promoting Health: A Practical Guide

BOX 2.1 Overview of the national standards for public health (Skills for Health 2007) – cont’d
7. Strategically lead the improvement of health and 6. Improve health and wellbeing through research and
wellbeing and the reduction of inequalities. development.
Area 9: Research and development to improve Area 10: Ethically managing self, people and
health and wellbeing – see Chapter 7 resources to improve health and wellbeing –
see Chapters 3 and 5–9
1. Plan, undertake, evaluate and disseminate research
and development about improving health and 1. Promote people’s equality, diversity and rights.
wellbeing. 2. Prioritise and manage own work and the focus of
2. Develop and maintain a strategic overview of activities.
developments in knowledge and practice. 3. Manage the use of financial resources.
3. Develop, implement and evaluate strategies to 4. Monitor and review progress with learners.
advance knowledge and practice. 5. Facilitate individual learning and development
4. Commission, monitor and evaluate projects to through mentoring.
advance knowledge and practice. 6. Enable individual learning through coaching.
5. Contribute to the evaluation and implementation of 7. Ethically manage self, people and resources to
research and development outcomes. improve health and wellbeing.

EXERCISE 2.3 Mapping your health promotion work against the standards for specialist practice in
public health
Study the areas identified as specialist public health practice and tick the level of activity you are involved in. Look at
Box 2.1 for details of the work covered by each area of activity.
Note the areas you work in and the areas that are outside your current job responsibilities or which you are not
trained to do.
Compare this mapping with that of colleagues or other health workers.
Very high
level of High level Fair level Some level No activity
Area of public health practice activity of activity of activity of activity in this area
Area 1: Surveillance and assessment of the     
population’s health and wellbeing.
Area 2: Promoting and protecting the population’s     
health and wellbeing.
Area 3: Developing quality and risk management     
within an evaluative culture.
Area 4: Collaborative working for health and     
wellbeing.
Area 5: Developing health programmes and     
services and reducing inequalities.
Area 6: Policy and strategy development and     
implementation to improve health and
wellbeing.
Area 7: Working with and for communities to     
improve heath and wellbeing.
Area 8: Strategic leadership for health.     
Area 9: Research and development.     
Area 10: Ethically managing self, people and     
resources.
Standards taken from Skills for Health (2007)
 Chapter 2 What is health promotion? 29

function. It will also help you to think about the performance, identifying their learning needs
differences between health promotion and public and defining the learning outcomes needed to
health. meet the national standards.
3. Education and training providers can use the
Using the National standards to modify their programmes to
Occupational Standards enable practitioners to develop appropriate
competencies, or use the standards as the basis
Broadly speaking there are three uses for the of their programme design.
national occupational standards:
1. Employers and managers can use the standards
to improve the quality of the performance of PRACTICE POINTS
their staff. An organisation can map what it is ■ Health promotion practice encompasses a wide
trying to achieve against the areas and sub- range of approaches that are united by the same
areas of practice. It can then look at its service goal, to enable people to increase control over and
specifications and its management of human improve their health.
resources through job specifications, staff ■ It is important for you to identify the full scope of
appraisal and performance review. The your health promotion work and to see how this fits
standards could also be used as the basis for with the work of your organisation or employer and
auditing a service and checking whether it the wider remit of public health.
meets quality standards. ■ The national standards for specialist practice in

Audit is discussed in more detail in Chapter 7. public health provide a map which can be used by
organisations, managers, education and training
2. Individuals can use the standards to improve providers, and individuals to improve the quality of
their competence through identifying their key public health and health promotion work.
areas of work, assessing their own

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