Why should health promoters be theoretical

Efforts at promoting health encompassing actions at individual and community levels, health system strengthening and multi sectoral partnership can be directed at specific health conditions.

It should also include settings-based approach to promote health in specific settings such as schools, hospitals, workplaces, residential areas etc. Health promotion needs to be built into all the policies and if utilized efficiently will lead to positive health outcomes. Health promotion is more relevant today than ever in addressing public health problems. The factors which aid progress and development in today's world such as globalization of trade, urbanization, ease of global travel, advanced technologies, etc.

There is a high prevalence of tobacco use along with increase in unhealthy dietary practices and decrease in physical activity contributing to increase in biological risk factors which in turn leads to increase in noncommunicable diseases NCD.

Illustration of how lifestyle-related issues contribute to increase in noncommunicable diseases 4. Health, as the World Health Organization WHO defines, is the state of complete physical, social and mental well being and not just the absence of disease or infirmity. The enjoyment of highest attainable standard of health is considered as one of the fundamental rights of every human being.

Health is heavily influenced by factors outside the domain of the health sector, especially social, economic and political forces. These forces largely shape the circumstances in which people grow, live, work and age as well as the systems put in place to deal with health needs ultimately leading to inequities in health between and within countries.

This holistic approach should empower individuals and communities to take actions for their own health, foster leadership for public health, promote intersectoral action to build healthy public policies and create sustainable health systems in the society.

It includes interventions at the personal, organizational, social and political levels to facilitate adaptations lifestyle, environmental, etc. Health promotion is not a new concept. The fact that health is determined by factors not only within the health sector but also by factors outside was recognized long back.

William Alison's reports on epidemic typhus and relapsing fever, Louis Rene Villerme's report on Survey of the physical and moral conditions of the workers employed in the cotton, wool and silk factories John Snow's classic studies of cholera , etc.

Sigerist, the great medical historian, who defined the four major tasks of medicine as promotion of health, prevention of illness, restoration of the sick and rehabilitation.

His statement that health was promoted by providing a decent standard of living, good labor conditions, education, physical culture, means of rest and recreation and required the co-ordinated efforts of statesmen, labor, industry, educators and physicians. It found reflections 40 years later in the Ottawa Charter for health promotion. Around the same time, the twin causality of diseases was also acknowledged by J. Ryle, the first Professor of Social Medicine in Great Britain, who also drew attention to its applicability to non communicable diseases.

Health education and health promotion are two terms which are sometimes used interchangeably. Health education is about providing health information and knowledge to individuals and communities and providing skills to enable individuals to adopt healthy behaviors voluntarily. It is a combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes, whereas health promotion takes a more comprehensive approach to promoting health by involving various players and focusing on multisectoral approaches.

Health promotion has a much broader perspective and it is tuned to respond to developments which have a direct or indirect bearing on health such as inequities, changes in the patterns of consumption, environments, cultural beliefs, etc. The Health Field concept spelt out five strategies for health promotion, regulatory mechanisms, research, efficient health care and goal setting and 23 possible courses of action.

Lalonde report was criticized by skeptics as a ploy to stem in the governments rising health care costs by adopting health promotion policies and shifting responsibility of health to local governments and individuals. The landmark concept also set the tone for public health discourse and practice in the decades to come. Growing expectations in public health around the world prompted WHO to partner with Canada to host an international conference on Health Promotion in The Ottawa Charter defined Health Promotion as the process of enabling people to increase control over and to improve their health.

To reach 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. The fundamental conditions and resources for health are: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity.

Health promotion thus is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well being. The Charter called for advocacy for health actions for bringing about favorable political, economic, social, cultural, environmental, behavioral and biological factors for health, enabling people to take control of the factors influencing their health and mediation for multi sectoral action.

The Charter defined Health Promotion action as one a which builds up healthy public policy that combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change to build policies which foster equity, b create supportive environments, c support community action through empowerment of communities - their ownership and control of their own endeavors and destinies, d develop personal skills by providing information, education for health, and enhancing life skills and e reorienting health services towards health promotion from just providing clinical and curative services.

This benchmark conference led to a series of conferences on health promotion - Adelaide , Sundsvall , Jakarta , Mexico-City , Bangkok and Nairobi In Adelaide, the member states acknowledged that government sectors such as agriculture, trade, education, industry and communication had to consider health as an essential factor when formulating healthy public policy.

The Sundsvall statement highlighted that poverty and deprivation affecting millions of people who were living in extremely degraded environment affected health. In Jakarta too poverty, low status of women, civil and domestic violence were listed as the major threats to health.

The Mexico statement called upon the international community to address the social determinants of health to facilitate achievement of health-related millennium development goals.

The Bangkok charter identified four commitments to make health promotion a central to the global development agenda; b a core responsibility for all governments c a key focus of communities and civil society; and d a requirement for good corporate practice. The health promotion emblem [ Figure 2 ] adopted at the first international conference on health promotion in Ottawa and evolved at subsequent conferences symbolizes the approach to health promotion.

The logo has a circle with three wings. It incorporates five key action areas in health promotion build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills and reorient health services and three basic HP strategies to enable, mediate and advocate.

This circle has three wings inside it which symbolise the need to address all five key action areas of health promotion identified in the Ottawa Charter in an integrated and complementary manner. The three wings represent and contain the words of the five key action areas for health promotion — reorient health services, create supportive environment, develop personal skills and strengthen community action. True to its recognition of health being more influenced by factors outside the health sector, health promotion calls for concerted action by multiple sectors in advocacy, financial investment, capacity building, legislations, research and building partnerships.

The multisectoral stakeholder approach includes participation from different ministries, public and private sector institutions, civil society, and communities all under the aegis of the Ministry of Health. Health promotion efforts can be directed toward priority health conditions involving a large population and promoting multiple interventions.

This issue-based approach will work best if complemented by settings-based designs. The settings-based designs can be implemented in schools, workplaces, markets, residential areas, etc to address priority health problems by taking into account the complex health determinants such as behaviors, cultural beliefs, practices, etc that operate in the places people live and work. Settings-based design also facilitates integration of health promotion actions into the social activities with consideration for existing local situations.

The conceptual framework in Figure 3 below summarizes the approaches to health promotion. It looks at the need of the whole population. The population for any disease can be divided into four groups a healthy population, b population with risk factors, c population with symptoms and d population with disease or disorder. Each of these four population groups needs to be targeted with specific interventions to comprehensively address the need of the whole population.

In brief, it encompassed primordial prevention for healthy population to curative and rehabilitative care of the population with disease. Primordial prevention aspires to establish and maintain conditions to minimize hazards to health.

It consists of actions and measures that inhibit the emergence and establishment of environmental, economic, social and behavioral conditions, cultural patterns of living known to increase the risk of disease. Health promotion measures are often targeted at a number of priority disease — both communicable and noncommunicable. The Millennium Development Goals MDGs had identified certain key health issues, the improvement of which was recognized as critical to development.

These issues include maternal and child health, malaria, tuberculosis and HIV and other determinants of health. Although not acknowledged at the Millennium summit and not reflected in the MDGs, the last two decades saw the emergence of NCD as the major contributor to global disease burden and mortality. NCDs are largely preventable by effective and feasible public health interventions that tackle major modifiable risk factors - tobacco use, improper diet, physical inactivity, and harmful use of alcohol.

Professor Haugan is supervising a number of PhD-projects focusing on different aspects of nursing home care. She also supervises nursing education research. Her research orientation includes qualitative and quantitative methods. Specifically, her research has contributed to the validation and investigation of the psychometric properties of a number of scales central to nursing, health and well-being. Member of the Global Working Group on Salutogenesis Now continuing the analysis and following salutogenic research up to date.

The most recent research is on salutogenic factors for sustainable working life for nurses. Previously worked as a hospital based social worker, operative director of an umbrella organization for people with disabilities, later as the Nordic investigator of mobility of people with disabilities. The content is easily transferable outside of nursing curricula.

Skip to main content Skip to table of contents. Advertisement Hide. This service is more advanced with JavaScript available. This Open access textbook presents salutogenic concepts representing health promoting assets Written experts at the forefront of the field Provides students, clinicians and researchers with a theoretical overview of health promotion and vital concepts Offers a vital resource for university courses in nursing and health sciences Written by experts from 11 universities in 7 countries in Europe, America, Africa and Asia.

Open Access. Peters et al. IM, however, describes the parameters of methods that are essential for both identifying successful methods in the literature and for developing intervention components For instance, modeling is effective only if reinforced and when observers pay attention, have adequate self-efficacy and skills, identify with the model, and observe a coping model instead of a mastery model Each theoretical method has its own conditions for effectiveness; for example, goal setting is effective only when the selected goal is challenging but attainable Fear arousal requires high self-efficacy expectations about behavior 18 , which can be difficult due of the complex nature of most behavior change settings.

Khan et al. Mesters et al. Moreover, inadequate reporting of theory and evidence-informed behavior change methods and their applications further limits the ability to advance the science of what works and makes program adaptation challenging. IM responds to the call for better understanding and reporting of intervention 27 , In Step 4, the various applications selected in Step 3 are organized and produced 2.

The program planning group decides the overall structure, themes, channels, and vehicles of the program. They design and produce materials that are culturally relevant and appealing, work with other stakeholders, and pilot-test the pertinent program elements.

The program planning group is responsible for correctly translating theoretical methods into practical applications, using the methods' parameters.

To this end, the program planning group and production professionals writers, video producers, graphic artists must work together to ensure that the final program products are appealing and accessible as well as reflect the key methods, practical applications, and messages developed during the planning process. Step 4 includes pretesting and ensures the implementation of effective program materials and program fit with the particular context and population.

Typically, during pretesting, comprehension, attractiveness, acceptance, believability, motivation, and preliminary indications of effectiveness are assessed, and recommendations for improvement are provided. Pretesting should be conducted after concept and message design and materials development but before materials are finalized 29 , It can be executed using experimental research designs 31 , focus groups, in-depth interviews, and intercept surveys, among other methods.

Effective health education and promotion programs can lose their impact if they are not used before desired health impacts are achieved 32 — IM provides a systematic process for the development of implementation strategies either for initial use of the program or for scale-up and spread of evidence-based programs already developed and tested. The use of IM to develop implementation strategies provides for the clear articulation of the mechanisms contained in these strategies, a gap in the implementation science literature 35 — Step 5 guides the development of implementation approaches, also known as strategies or interventions.

This step guides the planning group through thinking about adoption, implementation, and maintenance as well as who has to do what at each of these stages and why. Understanding the factors that influence implementation is critical for the selection of methods to address these factors. Program implementers are the people who are responsible for the delivery of the program and can include organizational leaders responsible for program adoption and maintenance as well as those responsible for actual delivery of program materials and activities to participants.

For example, nurses will present programs to patients, and teachers will deliver health education programs to students. Others in the organization or setting, even though they are not program implementers, may be responsible for making decisions about whether or not the program is adopted and for identifying individuals who will deliver the program.

For example, school principals may not deliver health education curriculum; however, their support for program adoption and maintenance is critical. IM Step 5 can be used not only to plan implementation the first time a program is developed and used but also can be used to develop plans for scale up and spread of existing evidence-based interventions.

Program planning groups can address program implementers' personal determinants, like knowledge and outcome expectations for the program and self-efficacy for enacting program activities at the individual level with methods, such as persuasive communication, tailoring, and modeling.

However, implementation almost always involves organizational change, which means program planning groups also have to apply methods at environmental levels. Organizational theory and implementation science frameworks can be used to understand the determinants and contextual factors that influence implementation and to guide the selection of methods that will support program implementation 38 , Effect and process evaluation will verify if the objectives chosen in Steps 2 and 5, respectively, have been reached, and need to be carefully planned.

Previous IM steps help inform the evaluation plan since behaviors, environments, their sub-components, and determinants are clearly spelled out 2. Fernandez et al. Special-topic authors provide examples of the application of IM across settings and topics 1. There are several examples of the use of IM for the development of eHealth interventions. Shegog and Begley 40 , using IM, involved both a diverse planning group and a patient provider advisory group to develop a decision support tool DST to increase self-management among epilepsy patients and their care providers.

The tool is used to increase awareness and efficacy of self-management behaviors among epilepsy patients and their healthcare providers and to improve communication during clinic visits.

The Shegog and Begley 40 paper includes a table that illustrates the identification of methods, organized by determinants, and how these were operationalized, using practical applications of the DST. The authors demonstrate how the online decision-support system in this case can include multiple methods and practical applications to address users' determinants of self-management.

Pot et al. In their study, mothers were the target group and were systematically involved in the development process. The mothers were ambivalent about HPV vaccination, and the intervention focuses on informed decision-making. The needs, behavioral outcomes, and targeted determinants are carefully described and include examples, and the full matrices of change objectives are found in the supplementary materials.

The web intervention combined freedom of choice with tunneling and virtual assistants who delivered the tailored feedback. The intervention was pilot-tested, and the implementation plan focuses on the web-based intervention owners. Rodriguez et al. The authors also used IM steps to adapt the intervention and create a module for parents of boys. The authors select and operationalize methods targeting parents' decision-making, with implicit recognition of parameters. They also describe using IM Step 5 for the development of implementation strategies delivery by lay health workers.

Serra et al. The authors developed a needs and asset assessment that included a review of factors that influence CRCS among Hispanics, taking into account the preferences of the target group, and collected data. They describe objectives at the level of behavior performance objectives and determinants change objectives. They identified two overarching methods: entertainment education and behavioral journalism.

The intervention materials included an interactive tablet-based application, print materials, an action plan, with a follow-up phone call to determine and address remaining barriers. As in the Shegog and Begley 40 and Rodriguez et al. Targeting health care providers directly was not possible, but a patient activation element patient-mediated prompts was added to the intervention to increase provider recommendations and referrals for CRCS.

Fassier et al. The authors emphasize the importance of taking an ecological perspective to planning and note that IM can help identify and document interpersonal, organizational, community, and societal influences.

They also describe the development of the planning group, which included a broad array of stakeholders who helped to identify priorities, and environmental conditions that influenced the return to work. The paper provides an example of the use of IM in the early stages of program development to understand a problem at multiple levels, develop a logic model of change, and guide assessment.

Using the socioecological approach that underlies the IM process, they identified important contributors to physical activity in the adolescent's social context, as based in social determination and social comparison theories. The paper is an example of how IM can assist in incorporating elements of different theoretical perspectives to inform program development. Vissenberg et al. The authors note that underlying the challenges to self-management behavior among these populations are cultural factors and socioeconomic status.

In line with IM, they recommend a greater engagement of the priority populations and other stakeholders in the planning process.

The article provides an example of a logic model as derived from the IM process. The authors noted that the literature suggests certain demographic, biological, and social determinants at three time periods: prenatal, postnatal initiation, and postnatal continuation. IM was used to describe performance and to develop change objectives.

Environmental factors included the mother's partner. An evaluation of the program showed that it resulted in positive behavioral changes, which the authors attributed to a careful analysis of the determinants and preparation for the unexpected negative attitudes of others Although IM provides guidance to identify needs and develop interventions, additional research and approaches are needed to more accurately address the questions posed by each of the steps including the identification of determinants and the selection of methods.

Crutzen et al. They suggest visualization of confidence intervals and correlations. The authors clearly explain the importance of identifying determinants. They also note that currently used approaches for identifying determinants are insufficient. They propose a confidence interval-based estimation of relevance CIBER approach for selecting determinants to target in an intervention.

The statistical tool is available at no cost. Additional research is needed to build the evidence base for the effectiveness of certain methods to address determinants. This research would then lead to basic experimental studies that test methods under various conditions. Meta-analyses of these experiments would then provide information about which methods are effective and under which conditions.

IM addresses the growing body of evidence on the influence of the environmental context on health and health behavior [e. Springer et al. Building from theoretical perspectives rooted in social-ecological models, improvement science, and systems thinking, this paper advances an indigenous health intervention development approach that takes into account the environmental context, to designing interventions.