Understanding Key Concepts of Health Education and Promotion

OEDOJO SOEDIRHAM
(oedojo@yahoo.com)
DEPARTMENT OF HEALTH PROMOTION
AND BEHAVIORAL SCIENCES
FKM-UNAIR, SURABAYA
OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 1

 HEALTH EDUCATION AND
HEALTH PROMOTION
 Introduction
 Definitions and Concepts
 Foundation for Practice
 Others

OVERVIEW
 Everyone engaged in the tasks of promoting health starts
with a view of what health is.
 However, there is a wide variety of these views, or concepts,

of health.
 It
is, important of the outset to be clear about the concepts of
health which you personally adhere to, and to recognize
where these differ from those of your colleagues and clients.
 Otherwise, you may find yourself drawn into conflicts about

appropriate strategies and advice that are actually due to
different ideas concerning the end goal of health.
 This lecture does not discuss about health only, but also
to present the process of attempting to promote health
that may include a whole range of interventions
including:
 Those which foster healthy lifestyle

 Those which encourage access to services and
involvement in health decisions
 Those which seek to promote an environment in which
the healthy choice becomes the easier choice
 Those which educate about the body and keeping
healthy
 Until the 1980s most of these interventions were
referred to as “health education” and the practice was
almost exclusively located within preventive medicine or,
to a lesser extent, education. In recent years, the term
health promotion has become widely used.
 This course considers whether this change in name

signifies a difference in ideology, policy, and practice.
 Using typology first suggested by Bunton and

Macdonald (1992), it describes the development of
health education and health promotion, and shows their
interdependent.

 The 19th century public health movement informed
the health education of the earlier part of the 20th
century which, in turn, informed the development of
health promotion.
 Itshows how the debate about the meaning of

health education and health promotion has
stemmed from a growing awareness that achieving
“Health For All” requires not just changes in
individual behavior, but also, social and
environmental change.

 The development of health education
 The origins of health education lie in the 19th century
when epidemic disease eventually led to pressure for
sanitary reform for the overcrowded industrial towns.
 Alongside the public health movement emerged the

idea of educating the public for the good of its health.
The Medical Officers of Health appointed to each town
under the Public Health legislation of 1848 frequently
disseminated everyday health advice on safeguards
against “contagion”. (Voluntary associations were also
formed including the London Statistical Society,1839;
the Health of Towns Association,1842; and the
Sanitary Institute, 1876).

 The Temperance Movement held Band of Hope
mass meetings, through schools and churches
lectured to young people on the virtue of
abstinence.
 By the 1920s health education had become

associated with diarrhoea, dirt, spitting and
venereal disease. The evidence that between
10% and 20% of soldiers in the First World War
had contracted venereal disease led to
propaganda, one-off lectures and the first use of
“shock-horror” techniques in which soldiers were
shown lurid pictures of diseased genitals to
dissuade them from having sex.
 Changing patterns of morbidity and mortality shifted
attention away from disease to personal behavior.
 TheCentral Council for Health Education was

established in 1972, paid for by local authority public
health departments and public health doctors
formed the majority of its membership.
 Anextract from some of the tasks listed as

important reflects an emphasis on information, and
education to bring about change in personal habits
and behavior”
 The provision of better and cheaper posters and
leaflets
 The provision of exhibits for exhibition
 The production of readable monthly bulletin
 The provision of a panel of lectures who really could

lecture and hold an audience

 The Central Council was principally concerned with
propaganda and instruction. During the Second
World War it delivered 3799 lectures on sex
education and venereal disease which were
attended by 340,000 people.
 But, according to Sutherland (1979) the two

principal functions or aims of the Central Council for
Health education were:

 Firstto promote and encourage education …
in the science and art of healthy living [and,
second], to coordinate the work of all
statutory bodies in carrying out their powers
and duties under the Public Health Acts …
relating to the promotion … of Public Health.

 Unfortunately, health education confined itself in the
main to the first, largely lifestyle, function and
neglected the second, largely structuralist, issue.
 Health promotion in the last 20 years or so has

attempted to fill that gap. It is worth noting,
however, that health in turn did not develop in a
vacuum but emerged as a consequence of the
public health measures of the late 19th and early
20th centuries.

 This lecture does not to conclude which one come
first, whether health education or health promotion.
Rather, to give information about what is “inside” of
those two:
 Is there any real different, both in concept and in
practice?
 Whatdo you think about these two tables below,

which one is more useful for you as public health
worker?

TABLE 1:
LEADING CAUSES OF DEATH IN THE UNITED STATES, 2000
DISEASES OF HEART 29.6

MALIGNANT NEOPLASMS (CANCER) 23.0
CEREBROVASCULAR DISEASES 7.0
CHRONIC LOWER RESPIRATORY DISEASES 5.1
ACCIDENTS (UNINTENTIONAL INJURIES) 4.1
DIABETES 3.0
INFLUENZA AND PNEUMONIA 2.7
ALZHEIMER’
ALZHEIMER’S DISEASE 2.1
KIDNEY DISEASES 1.5
SEPTICEMIA 2.3

TABLE 2:
ACTUAL CAUSES OF DEATH IN THE UNITED STATES,
2000
TOBACCO 18.1
POOR DIET AND PHYSICAL ACTIVITIES 15.2
ALCOHOL CONSUMPTIONS 3.5
MICROBIAL AGENTS 3.1
TOXIC AGENTS 2.3
MOTOR VEHICLE 1.8
FIREARMS 1.2
SEXUAL BEHAVIOR 0.8
ILLICIT DRUG USE 0.7

What is:
HEALTH?

 The river as a metaphor of health development has
often been used.
 Accordingto Antonovsky, it is not enough to

promote health by avoiding stress or by building
bridges keeping people from falling into the river.
Instead people have to learn to swim (Antonovsky
1987).

 The river of life is a simple way to demonstrate the
characteristics of medicine (care and treatment) and
public health (prevention and promotion) shifting the
perspective and the focus from medicine to public
health and health promotion towards population
health.

Cure or treatment of diseases
 The curative perspective on health
means that we ‘save people from
drowning’ using expensive high
technology and well-educated
professionals.
 Up stream thinking would offer people

support and interventions at an earlier
stage.
Health protection / disease
prevention
 This stage can be divided in two phases, i.e. the
protective and the preventive.
 The protective perspective means that the
interventions are limiting the risks of disease. The
efforts and interventions are population-based and
passive.
 In the metaphor of the river, the interventions are
aimed at preventing people from falling into the
river by ‘building fences’.
 The preventive perspective aims at preventing
diseases by active interventions characterized by an
empowering attitude where people are actively
involved.
 People are here ‘supplied with a life vest’. The

rationale is to reduce the negative effects and risks
thus maintaining the health of the public. The
interventions are both population-directed
(protective) and individual-based (preventive).

Health education/health promotion
 This stage consists both of health education and
health promotion.
 Health education has a long tradition in public

health practice. Originally, it was a question of the
professionals informing people of health risks and
giving advice how people should live their lives.

 Today it is based on a dialogue, involving people in
their own lives, making their own decisions
supported by the professionals. People are, in
general, more actively involved than in the previous
stages.
 The interventions are directed towards both
individuals and groups. Improved health literacy is
the key outcome of health education (Nutbeam,
2000).
 Returning to the river, the efforts here aim at
‘teaching people how to swim’.

 Inhealth promotion, health is seen as a
human right.
 The focus is on the co-ordination of activities
between professions and professionals in
societies.
 This is a positive concept emphasizing social
and personal resources as well as physical
capacities.

 The responsibility of health promotion action
extends far beyond the health sector and
health behavior to wellbeing and QoL.
 It
is a humanistic approach having the human
being, human rights at focus again.
 The individual becomes an active and

participating subject.
 The task for the professionals is to support and
provide options, enabling people to make sound
choices, point out the key determinants of health, to
make people aware of them and able to use them
(Lindström and Eriksson, 2006).
 Health education is here replaced by learning about

health referring to the reciprocity of a health
dialogue. The salutogenic perspective can be
applied in all these stages.

Improving health perception /
wellbeing / quality of life
 Going up-streams towards the source the last
stage deals with health perception and QoL.
 The ultimate objective of health promotion
activities is to create prerequisites for a good life.
 Perceived good health is a determinant for QoL.
The salutogenic framework can create a fusion of
the complexity of health and QoL development
(Eriksson and Lindström, 2006, 2007).

 Itis necessary to learn how to reflect on the options
of ones life situation, such as what generates health,
what improves QoL and what develops SOC.
 Traditionally, the difference between the biomedical
model and public health has been described through
a metaphor of a river moving from the down river
approach where people already are struck by
disease up streams through the stages described
above.

 However, to explain the shift of paradigm of the
salutogenic framework, the metaphor of the river is
different (salus = health; genesis = origin)
 Thisis Health in the River of Life. Here the river

flows vertically across your view. Along the front side
of the river, there is a waterfall continuously
following the whole stretch of the river. This means
the main flow and direction of the river is not down
the waterfall.

 At birth, we are dropped into the river and float with
the stream. The main direction is life not death and
disease in the waterfall.
 Some are born close to the opposite side of the river
where one can float at ease and the opportunities
for life are good and there are many resources at
disposal, like in a welfare state.
 Some are born close to the waterfall, at dis-ease,
where the struggle for survival is harder and the risk
of going over the rim is much greater.

 The river is full of risks and resources.
 However, the outcome is largely based on our ability

to identify and use the resources to improve our
options for health and life.

 BIOMEDICAL
 PSYCHOLOGICAL
 SOCIOLOGICAL (SOCIOCULTURAL)

BIOMEDICAL
 Focuses solely on the individual’s
physiological state
 Health is defined simply as the absence of

disease or physiological malfunction
 It is NOT positive state; but the absence of a

negative state

PSYCHOLOGICAL
 Asserts that individual constantly make
subjective evaluations of their own health

 Originally, this assessment was assumed to
focus solely on a general feeling of overall

well-being
 Psychological wellness includes
 Pleasurable involvement
 Long-term satisfaction
 The absence of negative affect
SOCIOLOGICAL (SOCIOCULTURAL)
 Emphasizes on the social and cultural
aspects of health and illness
 Focuses on the individual’s capacity to

perform roles and tasks and acknowledges
that there are social differences in defining
health

 Health promotion is the process of enabling people
to increase control over, and to improve, their
health.
 Toreach a state of complete physical, mental, and

social well-being, an individual or group must be
able to identify and to realize aspirations, to satisfy
needs, and to change or cope with the environment.
 Health
is, therefore, seen as a resource for
everyday life, not the objective of living.

 Health is a positive concept emphasizing
social and personal resources, as well as
physical capacities.
 Therefore, health promotion is not just the

responsibility of the health sector, but goes
beyond healthy life styles to well-being

 PREREQUISITIES FOR HEALTH
 Peace
 Shelter
 Education
 Food
 Income
 A stable eco-system
 Sustainable resources
 Social justice
 Equity

HEALTH PROMOTION ACTION
MEANS
 BUILD HEALTHY PUBLIC POLICY
 CREATE SUPPORTIVE ENVIRONMENTS
 STRENGTHEN COMMUNITY ACTION
 DEVELOP PERSONAL SKILLS
 REORIENT HEALTH SERVICES

These actions are
interdependent,
but healthy public
policy establishes
the environment
that makes the
other four

1. Healthy Public Policy
 Healthy public policy is a pre-requisite for successful

health promotion.
 A Healthy Public Policy is characterized by a concern for
health and equity and an accountability for health impact.
 Health should be made a priority item on the agenda of
policy-makers in all sectors.
 Policy-makers should be made aware of the health
consequences of their decisions. They should create pro-
health policies, whether in the area of development,
legislation, taxation etc.

 Healthy public policy covers a combination of diverse but
complementary measures and approaches such as legislation,
taxation, fiscal incentives and disincentives, policy analysis
and review, and organizational change
 Joint action by all sectors will contribute to achieving safer and

healthier goods and services, healthier public services, and
cleaner and more healthy environment.
 The aim is to make the healthier choice the easier choice for
all people.
 HPP should lead to the creation of a supportive environment to

enable people to lead healthy live

 According to the Adelaide Conference (1988), “The main aim
of HPP is to create a supportive environment to enable the
people to lead healthy lives. Healthy choices are thereby
made possible and easier for citizens”.
 All relevant government sectors like agriculture, trade,

education, industry and finance need to give important
consideration to health as an essential factor during their
policy formulation.

2. Create Supportive Environment
 A supportive environment is essential for health.

 Supportive environments cover the physical, social,
economic, and political environment.
 Supportive environments encompass where people live,
work and play. This is what is envisaged by the “settings”
approach.
 Everyone has a role in creating supportive environments for
health.

3. Strengthen Community Action:
Community Participation
 According to the Ottawa Charter, “health promotion works
through concrete and effective community action in setting
priorities, making decisions, planning strategies and
implementing them to achieve better health”.
 There are many ways of defining community.
 Factors used are geography, culture and social stratification.

 Community action is any activity undertaken by a
community in order to effect change (including
voluntary and self-help services).
 Community participation covers a spectrum of
activities
 At the low end, it may be token participation in the
form of consultation or endorsing plans drawn up by
the health authorities. At the high end, it may be in
the form of ‘people power’ where they have full say
in identifying needs, setting priorities, planning
strategies and activities and implementing the
program.

 Fullcommunity participation occurs when
communities participate in equal partnership with
health professionals as stakeholders in setting the
health agenda.
A Definition (Rifkin et al. 1988)

Community participation is a social process
whereby groups with shared needs living in a
defined geographic area actively pursue
identification of their needs, take decisions and
establish mechanisms to meet these needs

 According to the Jakarta Declaration (1997), “health
promotion improves both the ability of individuals to
take action, and the capacity of groups, organizations
or communities to influence the determinants of
health”.
 Empowerment is an important strategy, based on the

notion that health is significantly affected by the extent
to which one has control or power over one’s life.

4. Develop Personal Skills
 Strategies for empowering the community include
leadership training, learning opportunities for health,
and access to resources including material and
funding
 Empowerment helps people to identify their own needs
and concerns, and gain the power, skills and
confidence to act upon them. It is a bottom-up strategy
which requires the health promoter to act as a
facilitator and catalyst for change.

 Skillswhich can promote an individual’s health include
those pertaining to identifying, selecting and applying
healthy options in daily life.
 Health education is life-long, so that people can
develop the relevant skills to meet the health
challenges of all stages of life, and to be able to cope
with chronic illness and disabilities.
 Health education should be conducted in all settings.

5. Reorient Health Services
 Shiftof emphasis from provision of curative
services.
 Health care system must be equitable and client-
centered.
 May necessitate reengineering and organizational
change, especially in the areas of professional
education and training, management, recruitment
and deployment of health personnel, and planning,
development and delivery of services,

 Why study health promotion theory?
 Although it is clear why public health practitioners
and students of public health should learn about
how to devise and implement health promotion
interventions, it may be less obvious why it is
necessary to spend time learning about the theory
of health promotion. As this book makes clear,
health promotion is far from straightforward.

 Why study health promotion theory?
 Unless public health practitioners explore and
understand the theory underpinning health
promotion, there is a real risk, at best, of
establishing ineffective interventions and, at worst,
of antagonizing and even harming the very people
you are seeking to help.

 Health promotion is probably the most ethical,
effective, efficient and sustainable approach to
achieving good health.
 It was defined initially by the World Health
Organization in 1986, but the definition has since
been refined to take account of new health
challenges and a better understanding of the
economic, environmental and social determinants of
health and disease.

 Health is the most sought after subject on the World
Wide Web. The problem of definition is confusing
because terms such as health (and education and
promotion) are widely used in everyday language
and, as such, are used to mean very different things
in different contexts. These are essentially contested
concepts, as they are used and abused, in the
familial sense, in everyday language.


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OEDOJO SOEDIRHAM

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 1

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 2

 However, there is a wide variety of these views, or concepts,

 Otherwise, you may find yourself drawn into conflicts about

 Those which foster healthy lifestyle

 This course considers whether this change in name

 Using typology first suggested by Bunton and

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 5

 Itshows how the debate about the meaning of

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 6

 Alongside the public health movement emerged the

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 7

 By the 1920s health education had become

 TheCentral Council for Health Education was

 Anextract from some of the tasks listed as

 The provision of exhibits for exhibition

 The production of readable monthly bulletin

 The provision of a panel of lectures who really could

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 10

 But, according to Sutherland (1979) the two

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 11

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 12

 Health promotion in the last 20 years or so has

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 13

 Whatdo you think about these two tables below,

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 14

DISEASES OF HEART 29.6

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 15

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 16

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 17

 Accordingto Antonovsky, it is not enough to

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 19

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 20

 Up stream thinking would offer people

 People are here ‘supplied with a life vest’. The

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 23

 Health education has a long tradition in public

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 24

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 25

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 26

 The individual becomes an active and

 Health education is here replaced by learning about

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 28

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 29

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 30

 Thisis Health in the River of Life. Here the river

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 31

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 32

 However, the outcome is largely based on our ability

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 33

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 34

 Health is defined simply as the absence of

 It is NOT positive state; but the absence of a

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 35

subjective evaluations of their own health

focus solely on a general feeling of overall

aspects of health and illness

 Focuses on the individual’s capacity to

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 37

 Toreach a state of complete physical, mental, and

OEDOJO SOEDIRHAM (oedojo@yahoo.com) 9/11/2019 38

 Therefore, health promotion is not just the