Health Promotion Theoretical Frameworks

1. Health Promotion Theoretical Frameworks Jennie Naidoo and Nick de Viggiani June 2009

2. Why theory? • Health promotion is a practical enterprise, we should just get on and do it. Professionals are well equipped to promote people’s health. • Theory is important because it makes explicit our aims and our choice of strategies. Theory is necessary to achieve transparency and accountability. Theory helps to ensure we select the most effective and acceptable strategies and ways of working. Theory helps demarcate health promotion practice.

3. The role of theory • Theory is the representation of reality in a way that seeks to make explicit underlying factors, connections and outcomes • Theory helps us explore reality and identify changes we might seek to make • Theory identifies the range of possible interventions and their ramifications, as well as factors that might impede progress

4. Definition of theory • “systematically organized knowledge applicable in a relatively wide variety of circumstances devised to analyze, predict or otherwise explain the nature or behaviour of a specified set of phenomena that could be used as the basis of action” (Van Ryn and Heaney, 1992)

5. Health promotion theories • There are many different theories that guide health promotion interventions • Most theories are based in the social sciences including sociology, education, psychology and policy studies • Different approaches to health promotion tap into different theoretical perspectives and academic disciplines

6. 5 different approaches to health promotion • Medical • Behaviour change • Educational • Empowerment • Social change

7. Medical • Relies on a medical view of health and professional interventions based on medical science e.g. immunisation • Includes primary, secondary and tertiary prevention

8. Behaviour change • The aim is to encourage individuals to adopt healthy behaviours • There are many different models of how to achieve behavioural change, including factors such as media coverage, the example of role models, information, and supportive environments • This is a popular approach because it is focussed on individuals and retains a role for the professional who gives information and advice

9. Theory of Planned Behaviour (Ajzen 1991)

10. Education • The aim is to provide information to enable people to make informed choices re. their health • learning involves 3 aspects: • Cognitive (information and understanding) • Affective (attitudes and feelings) • Behavioural (skills)

11. Empowerment • Enables people to gain control over their lives • Seen as ethically sound because it supports autonomy and free choice • Can be individually or community focussed

12. Social change • The focus is to change the socio-economic environment to enable people to make healthier choices and adopt healthier behaviours – to make the healthy choice the easier choice • This is a top-down approach including policy change, media advocacy and legislation

13. Stages of change model (Prochaska and DiClemente 1984, 1986) A cyclical process with the following stages: • Precontemplation • Contemplation • Ready to change • Making a change • Maintaining the change • Relapse

14. Health Promotion Theoretical Models • There are many health promotion models and theoretical frameworks that seek to explain and explore how health can be promoted. • We will examine 3 contrasting models: Beattie 1991, Green and Kreuter 2005, and Dahlgren and Whitehead 1991

15. Beattie 1991, 1993 • Beattie’s model uses 4 paradigms generated from the dimensions of mode of intervention (authoritative, negotiated, bottom up – vertical axis) and focus of intervention (individual to collective – horizontal axis). The resulting 4 paradigms correlate to different political perspectives.

17. Green and Kreuter (2005) : Precede-Proceed Model • This planning model focuses on the identification of predisposing, reinforcing and enabling factors in order to diagnose an appropriate response (media advocacy, policy, organisational change, health education)

18. PRECEDE-PROCEED Framework Phase 5 Administrative Policy Assessment Phase 4 Educational & Ecological Assessment Phase 3 Behavioral & Environmental Assessment Phase 2 Epidemiologic Assessment Phase 1 Social Assessment Predisposing factors Health services Behavior & lifestyle HealthEducation Health Promotion Policy,Regulation Quality of life Reinforcing factors Health Environment Enabling factors Phase 7 Process Evaluation Phase 8 Impact Evaluation Phase 9 Outcome Evaluation Phase 6 Implementation

19. Dahlgren and Whitehead 1991 • This model identifies the determinants of health ranging, from the individual to the societal to the global. • It is often used to flag up issues re. inequalities in health as it makes clear the constraints on individuals arising from social, cultural, economic and environmental factors. • This model also identifies the need for structural interventions to impact on the causes of health and illhealth

21. References • Beattie, A (1991) ‘Knowledge and control in health promotion: A test case for social policy and social theory’ in Gabe, J Calnan, M Bury, M (Eds) The sociology of the health service London, Routledge • Dahlgren, G and Whitehead, M (1991) Policies and strategies to promote social equity in health Stockholm, Institute of Futures Studies • Green, LW and Kreuter, MW (2005) Health promotion Planning: An educational and ecological approach 4th edn. New York, McGraw Hill • Naidoo, J and Wills, J (2000) Health Promotion: Foundations for Practice 2nd Edn London Bailliere Tindall NB 3rd Edn. In press, due 2009

22. References con’t • Prochaska, JO and DiClemente, C (1986) ‘Towards a comprehensive model of change’ in Miller, WR and Heather, N (Eds) Treating addictive behaviours: Processes of change New York, Plenum • Van Ryn, M and Heaney, CA (1992) ‘What’s the use of theory?’ Health Education and Behaviour Vol. 19 No. 3: 315-330 • Wills, J (2007) ‘Theoretical perspectives on promoting public health’ in Earle, S Lloyd, CE Sidell, M and Spurr, S Theory and Research in Promoting Public Health London, Sage Open University