Health Promotion

1. Health Promotion Health Psychology

2. Concerns of health promotion (Ewles and Simnett, 1992) • Health education programmes - to raise awareness of health risk and to encourage behaviour change • Primary health education - to prevent ill health developing (e.g. diet, hygiene, social skills, etc)

3. Concerns of health promotion (Ewles and Simnett, 1992) • Preventive health services - e.g. family planning, immunisation and well person clinics • Community-based work - local communities identify health problems and address them • Healthy public policies - housing, employment, transport, etc

4. Concerns of health promotion (Ewles and Simnett, 1992) • Environmental health issues - making the physical environment safer - e.g. tackling pollution. • Economic and regulatory activities - e.g. trying to get the government to raise tax on tobacco, etc

5. The Ottawa Charter for Health Promotion (WHO 1986) identified the following features that it believed were necessary for good health: • · Peace • · Shelter • · Education • · Food • · Income • · A stable ecosystem • · Sustained resources • · Social justice • · Equity

6. Models • The medical model • The behaviour change model • The educational model • The empowerment model • The social change model

8. Medical model • Prevention • Primary - before illness starts • One of the famous stories of early health promotion concerns the Broad Street pump in Soho, London. In 1854, Dr. John Snow plotted cases of cholera on a map of London and noticed that they clustered around a water pump on Broad Street.

9. Medical model • At that time, water in London was provided by a number of private companies, and Snow discovered that the death rate from cholera was much higher for people using water from two of these companies (71 deaths per 10,000 people) than the others (only 5 deaths per 10,000 people). Snow’s observation of the pattern of cases around Soho allowed him to carry out a natural experiment. He disabled the Broad Street pump by removing the handle (hi-tech or what?) and the cholera epidemic subsided in the area. From this, Snow was able to show that cholera was carried in water (Donaldson and Donaldson, 2000.)

10. Primary Prevention • Genetic counselling. Future parents are able to get important information about the possibility of their future child being born with a genetic disorder. Factors such as the age of the parents and the results of biological tests may be taken into account. Tests can be made on the unborn foetus, but such techniques are hazardous to the foetus.

11. Primary Prevention • Immunisation of children would also be a way of preventing illnesses. • The analysis of questionnaires about health behaviour could also be useful in helping people to adopt a healthy lifestyle.

12. Secondary prevention • Secondary prevention concerns identifying an illness fairly early, before there has been much damage. It used to be thought that an annual check-up would identify imminent illnesses, but it is now thought that between 6 and 10 specific tests can suffice. The American cancer society (1992) recommended that women should have mammograms (breast x-ray), but recently, in Britain, this practice has been called into question. Colon inspections are recommended for those over 40.

13. Mammogram

14. Mammogram

15. Breast Self-Examination

16. Cancer and Breast Self-Examination • BSE effective in early detection of Breast Cancer. Pitts (1991) <30% British women perform BSE • Meyerowitz and Chaiken (1987) the effectiveness of Gain and Loss messages. Gain message worked best. Therefore campaigns should use a positive message.

17. Cancer and Breast Self-Examination • The BSE instructions are rather complicated. a simpler procedure called `Breast awareness' has been introduced. As the procedure is simpler, women are more confident in being able to carry it out. The procedure produces less false positives. This is when the person falsely identifies a problem, or believes they may be developing breast cancer, when they are not (Murray and McMillan, 1993).

18. Colon Cancer

19. Testicular Cancer • From the time of puberty onwards you should do a simple quick check of yourself regularly. This will help you to know what is normal for you (everyone is different) and you will be able to detect any changes early on.

20. Testicular Cancer • A good place to do this is in, or immediately after a bath or a shower, when the muscle in the scrotal sac is more relaxed. • You could ask your partner to help. • Hold your scrotum in the palm of your hands, so that you can use the fingers and thumb on both hands to examine your testicles.

21. Testicular Cancer • Note the size and weight of the testicles. It is common to have one slightly larger, or which hangs lower than the other, but any noticeable increase in size or weight may mean something is wrong. • Gently feel each testicle individually

22. Testicular Cancer • You should feel a soft tube at the top and back of the testicle. This is the epididymis which carries and stores sperm. It may feel slightly tender. Don’t confuse it with an abnormal lump. • You should be able to feel the firm, smooth tube of the spermatic cord which runs up from the epididymis.

23. Testicular Cancer • Feel the testicle itself. It should be smooth with no lumps or swellings. It is unusual to develop cancer in both testicles at the same time, so if you are wondering whether a testicle is feeling normal or not, you can compare it with the other.

24. Tertiary Prevention - containing or slowing down the damage

25. Barriers to Primary Prevention • • we have only limited knowledge about what behaviours are threatening to our health, for example, it is only in the last forty years that we have discovered the very harmful effects of tobacco smoking

26. Barriers to Primary Prevention • • we have a lack of knowledge about how we develop health-threatening behaviours, for example, some behaviours to do with diet or exercise develop over many years from our childhood • • a number of health behaviours are learnt in the home, for example, the children of smokers are more likely to smoke than the children of non­smokers

27. Barriers to Primary Prevention • • at the time that health threatening behaviours develop, people often have little immediate incentive to practice health enhancing behaviours, for example the effects of smoking are felt in middle to later life rather than when people start smoking • • people are often unrealistically optimistic about their health

28. 3 main reasons why primary prevention has been ignored • Traditional structure of medicine • Difficulty of getting people to practice healthy behaviours • Difficulty in applying methods of attitude and behavioural change to health

29. THREE APPROACHES TO HEALTH PROMOTION • Behaviour change approach • Objective: to bring about changes in individual behaviour through changes in individuals' cognitions. • Process: provision of information about health risks and hazards.

30. THREE APPROACHES TO HEALTH PROMOTION • Behaviour change approach • Aim: . to increase individuals' knowledge about the causes of health and illness. . • Assumption: humans are rational decision-makers whose cognitions inform their actions.

31. THREE APPROACHES TO HEALTH PROMOTION • Self-empowerment approach • Objective: to empower individuals to make healthy choices. • Process: participatory learning techniques. • Aim: to increase control over one's physical, social and internal environments. • Assumption: power is a universal resource which can be mobilised by every individual.

32. THREE APPROACHES TO HEALTH PROMOTION • Collective action approach • Objective: to improve health by addressing socio-economic and environ­mental causes of ill health. . • Process: individuals organize and act collectively in order to change their physical and social environments.

33. THREE APPROACHES TO HEALTH PROMOTION • Collective action approach • Aim: to modify social, economic and physical structures which generate ill . health. • Assumption: communities of individuals share interests which allows them to act collectively.

34. BEHAVIOUR CHANGE APPROACH • Consider how the issue of smoking is dealt with by the Health Belief Model (HBM; Becker, 1974). Smokers deciding whether or not to give up smoking would be expected to consider: • how susceptible they are to lung cancer and other smoking-related conditions; • how serious these conditions are; • the extent and value of the benefits of giving up smoking; • the potential negative consequences of giving up smoking.

35. BEHAVIOUR CHANGE APPROACH • In addition, the HBM acknowledges the role of cues to action, internal (e.g. a symptom such as a smoker's cough) and external (e.g. information, advice or meeting someone with lung cancer), as well as health motivation, and the importance of health to the individual.

36. BEHAVIOUR CHANGE APPROACH • The HBM has been applied to a wide range of health behaviours including the uptake of flu vaccinations, breast self-examination, anti­hypertensive regimes, mothers' adherence to regimens for their children and risk factor behaviours (e.g. seatbelt use, attendance at health check­ups, diets, etc.). Overall, the 'HBM is marginally successful in predicting health behaviours. Each key variable of the HBM tends to be significantly correlated with the behaviour under study.

37. BEHAVIOUR CHANGE APPROACH • This suggests that the variables identified by the HBM are relevant ingredients and contribute to the process which generates health behaviour. However, our ability to accurately predict health behaviour on the basis of the HBM is severely limited.

38. BEHAVIOUR CHANGE APPROACH • The theory of reasoned action (TRA; Fishbein and Ajzen, 1975) and its revised version, the theory of planned behaviour (TPB; Ajzen, 1985) propose that behaviour is informed by attitudes towards the behaviour as well as subjective norms about the behaviour, that is what significant others think one should do. These variables (and in the case of the TPB an additional variable: perceived control over the behaviour) combine to generate an intention to behave in a particular way, which is then used to predict actual behaviour.

39. BEHAVIOUR CHANGE APPROACH • Attitudes and subjective norms are based upon beliefs held by the individual. So, for example, a woman's belief that birth control pills are a potential health risk and her belief that her friends and relatives would not approve of her taking such a risk are thought to generate a negative attitude towards taking birth control pills, as well as social pressure not to take them; thus giving rise to the intention to refrain from the use of birth control pills and, hopefully, to consider other forms of contraception.

40. BEHAVIOUR CHANGE APPROACH • The TRA and TPB have been used to predict numerous health behaviours, including smoking, alcohol consumption, contraceptive use/safer sex, health screening attendance, exercise, food choice and breast/testicle self-examination. Overall, the evidence suggests that TRA and TPB do contribute to our understanding of the antecedents of health relevant behaviours.

41. BEHAVIOUR CHANGE APPROACH • However, it is important to bear in mind that the TRA and TPB do not actually predict behaviour but only the intention to behave. Unfortunately, correlations between intention to behave and actual behaviour are not perfect. They tend to range between 0.45 and 0.62.

42. A study using the TRA (Rise, 1992) • Rise (1992) used the TRA as a theoretical framework in order to study 'condom behaviour' defined as 'a decision based upon consideration of the expected consequences of using or not using condoms'. A postal questionnaire about condom use was completed by 1,172 Norwegian adolescents aged 17 to 19 years and all non-virgins.

43. A study using the TRA (Rise, 1992) • The following variables were measured: • The intention to use condoms at the next intercourse (behavioural intention). . • Beliefs about condom use, e.g. 'condoms protect me against sexually transmitted diseases' (behavioural beliefs). • Evaluation of behavioural beliefs and outcomes, e.g. 'How much do you fear STD?' (values). • Significant others' evaluation of the respondent's condom use (normative beliefs). , • Importance of significant others' evaluation (motivation to comply). Previous/habitual condom use (prior behaviour).

44. A study using the TRA (Rise, 1992) • Rise (1992) observed that past behaviour was by far the strongest predictor of intention to use condoms at the next intercourse. Next came subjective norm followed by attitude. All relationships were statistically significant. Behavioural beliefs related to pleasure and sensation (e.g. 'Condom use reduces my physical pleasure') discriminated best between intenders and non-intenders whereas traditional risk appraisal beliefs (e.g. 'Condom use protects me against STD') did not discriminate. Among normative beliefs, sexual partners' expectations had the best discriminatory power. '.

45. CRITICISMS OF SCMS • 1 SCMs are only concerned with cognitively mediated behaviours. • 2 SCMs do not take into account the direct effect of impulse and/or emotion. • 3 SCMs assume that the same variables inform different health behaviours. • 4 SCMs assume that the same variables are relevant for diverse groups of people. • 5 SCMs focus exclusively upon mental representations of the social world and do not take into account the direct effects of material, physical and social factors. • 6 SCMs do not address the issue of joint decision making.

46. Criticisms of the behaviour change approach • . is unable to target the major socio-economic causes of ill health; • . operates top-down; • . assumes that there is a direct link between knowledge, attitudes and behaviour; • . assumes homogeneity among the receivers of health promotion messages.

47. SELF-EMPOWERMENT APPROACH • The goal of this approach to health promotion is to empower individual people to make healthy choices. Self-empowerment can be defined as the process by which groups and individuals increase their control over their physical, social and internal environments. In order to facilitate self-empowerment, participatory learning techniques allow people to examine their own values and beliefs and explore the extent to which factors such as past socialization as well as social location affect the choices they make (Homans and Aggleton, 1988).

48. SELF-EMPOWERMENT APPROACH • Group work, problem-solving techniques, client-centred counselling, assertiveness training and social skills training as well as educational drama are forms of participatory learning. The self-empowerment paradigm, with its emphasis upon self-awareness and skills, resonates with what Stroebe and Stroebe (1995) refer to as the 'therapy model' of health promotion which deploys a wide range of psychological techniques such as cognitive restructuring, skill training and self-conditioning in order to help individuals act upon their intentions to adopt health behaviours.

49. SELF-EMPOWERMENT TECHNIQUES • Participatory learning • Group work • Problem solving • Client-centred counselling • Assertiveness training • Social skills training • Educational drama

50. Self-empowerment • Self-empowerment is particularly popular within health education for young people. For example, peer pressure has been identified as a powerful obstacle to the adoption of healthy practices by young people. Here, self-empowerment techniques encourage young people to make independent decisions by developing their psychological resources to resist peer pressure, the so-called 'say no' technique. This has been attempted through assertiveness training, social skills training, inoculation to persuasive appeals and life skills training, with limited success (Hopkins, 1994).