MODELS OF HEALTH PROMOTION

1. MODELS OF HEALTH PROMOTION

2. Objectives: You students will • Understand the parameters required for health promotion model • Be able to apply those parameters on models they may suggest for your own society

3. MODEL OF HEALTH PROMOTION 1: FOUR PARADIGMS OF HEALTH PROMOTION (CAPLAN AND HOLLAND - 1990) Radical change Nature of society • RADICAL HUMANIST • Holistic view of health • De-professionalization • Self-help networks • RADICAL STRUCTURLIST • Health reflects structural inequalities • Need to challenge inequity and radically transform society. Subjective Objective Nature of knowledge • HUMANIST • Holistic view of health • Aims to improve understanding and development of self • Client-led • TRADITIONAL • Health = absence of disease • Aim is to change behaviour • Expert-led Social regulation

4. MODEL OF HEALTH PROMOTION 2: HEALTH PROMOTION METHODS USING BEATTIE’S TYPOLOGY (BEATTIE – 1991) MODE OF INTERVENTION Legislation Policy making and implementation Health surveillance Advice Education Behaviour change Mass media campaign Authoritarian Individual Collective Focus of intervention Counselling Education Group work Lobbying Action research Skills sharing and training Group work Community development Negotiated

5. MODEL OF HEALTH PROMOTION 3: A TYPOLOGY OF HEALTH PROMOTION (FRENCH – 1990) • DISEASE MANAGEMENT • Curative services • Management services • Caring services • HEALTH EDUCATION • Agenda setting • Empowerment and support • Information • DISEASE PREVENTION • Preventive services • Medical services • Behaviour change • POLITICS OF HEALTH • Social action • Policy development • Economic and fiscal policy

6. MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE et al – 1990) 5 6. Positive health protection, e.g. workplace smoking policy. 7. Health education aimed at positive health protection, e.g. lobbying for a ban on tobacco advertising. 1.Preventive services, e.g. immunization, cervical screening, hypertension case finding, developmental surveillance, use of nicotine chewing gum to aid smoking cessation. 2.Preventive health education, e.g. smoking cessation advice and information. Health education 7 2 4 6 1 Health protection 3 Prevention 3. Preventive health protection, e.g. fluoridation of water. 4. Health education for preventive health protection, e.g. lobbying for seat belt legislation. 5. Positive health education, e.g lifeskills with young people.

7. MODEL OF HEALTH PROMOTION 5: THE CONTRIBUTION OF EDUCATION TO HEALTH PROMOTION (TONES et al – 1990) Public pressure Healthy public policy Lobbying Advocacy Mediation Healthy social and physical environment Empowered participating community Healthy promoting organisation Healthy services HEALTH Critical consciousness raising Agenda setting Healthy choices Professional education Education for health

8. APPROACHES TO HEALTH PROMOTION

9. Approaches in Health Promotion: the example of healthy eating Approach Aims Methods Worker/client relationship Medical To identify those at risk from disease. Primary health care consultation. e.g. measurement of body mass. Expert-led. Passive, conforming client.

10. Approaches in Health Promotion: the example of healthy eating Approach Aims Methods Worker/client relationship Persuasion through one-to-one advice, information, mass campaigns, e.g. ‘Look After Your Heart’ dietary messages. Expert-led. Dependent client. Victim blaming ideology. Behavior change To encourage individuals to take responsibility for their own health and choose healthier lifestyles.

11. Approaches in Health Promotion: the example of healthy eating Approach Aims Methods Worker/client relationship Educational To increase knowledge and skills about healthy lifestyles. Information. Exploration of attitudes through small group work. Development of skills, e.g. women’s health group. May be expert led. May also involve client negotiation of issues for discussion.

12. Approaches in Health Promotion: the example of healthy eating Approach Aims Methods Worker/client relationship Empowerment To work with client or communities to meet their perceived needs. Advocacy Negotiation Networking Facilitation e.g. food co-op, fat women’s group. Health promoter is facilitator, client becomes empowered.

13. Approaches in Health Promotion: the example of healthy eating Approach Aims Methods Worker/client relationship Social change To address inequalities in health based on class, race, gender, geography. Development of organizational policy, e.g. hospital catering policy Public health legislation, e.g. food labelling. Fiscal controls, e.g. subsidy to farmers to produce lean meat. Entails social regulation and is top-down.

14. Religion and Health - 3 Quran & Ahadith Five Pillars of Islam Islamic Jurisprudence Elements of Faith Salutogenic Mechanism Predisposing & Enabling factors Sense of coherence Behavior Figure 1: Pathways of ‘Islamic Health Theory’ Healthy Lifestyle

15. Do Plan Check Act Putting Islamic Concepts Into Practice for Health Promotion 1

16. Precede-proceed model. Intervention mapping. A five-stage model. Putting Islamic Concepts Into Practice for Health Promotion 2

17. Putting Islamic Concepts Into Practice for Health Promotion 2.1 The PRECEDE-PROCEED Model by Green & Kreuter, 1999 Visit the website below for a figure of this model. http://oc.nci.nih.gov/services/Theory_at_glance/PP_Part_3_cont.html#anchor248267

18. Intervention mapping. Putting Islamic Concepts Into Practice for Health Promotion 2.2 STEP 1: Proximal program objective matrices STEP 2: Theory –based methods and practical strategies STEP 3: Program plan STEP 4: Adoption and implementation plan STEP 5: Evaluation plan

19. A five-stage model (Bracht et al. 1999) Putting Islamic Concepts Into Practice for Health Promotion 2.3 1. Community analysis COMMUNITY ORGANIZATION STAGES 5. Dissemination - reassessment 2. Design - initiation 4. Maintenance - consolidation 3. Implementation

20. 1. Community analysis. Putting Islamic Concepts Into Practice for Health Promotion 3.1 An illustration using the five-stage model (Bracht et al. 1999)

21. 2. Design - initiation. Putting Islamic Concepts Into Practice for Health Promotion 3.2 An illustration using the five-stage model (Bracht et al. 1999)

22. 3. Implementation. Putting Islamic Concepts Into Practice for Health Promotion 3.3 An illustration using the five-stage model (Bracht et al. 1999)

23. 4. Maintenance - consolidation. Putting Islamic Concepts Into Practice for Health Promotion 3.4 An illustration using the five-stage model (Bracht et al. 1999)

24. 5. Dissemination - reassessment. Putting Islamic Concepts Into Practice for Health Promotion 3.5 An illustration using the five-stage model (Bracht et al. 1999)

25. Promoting Healthy Behavior

26. Behavior and Global Health “Health is a state of complete physical, psychological, and social well-being and not simply the absence of disease or infirmity.” (World Health Organization, 1948) • Physical good health eludes billions of people • Death and disease from preventable causes remain high • Behavior is a key factor in determining health

27. Maternal and child underweight Unsafe sex High blood pressure Tobacco Alcohol Unsafe water, poor sanitation, & hygiene High cholesterol Indoor smoke from solid fuels Iron deficiency High body mass index or overweight Ten Leading Risk Factorsfor Preventable Disease Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002), accessed online at www.who.int, on Nov. 15, 2004.

28. Whose Behavior is Responsible For… • Maternal and child underweight • Smoking and alcohol abuse  • Unsafe sex  • Unsafe water and lack of adequate sanitation 

29. Maternal and Child Underweight • Individuals (may resist nutrition education) • Communities (male preference norms) • Policymakers (fail to address poverty) • Health planners and health workers (do not include nutrition programs for the poor) 

30. Smoking and Alcohol Abuse • Individuals (choice) • Communities (norms regarding smoking) • Health policymakers • Legislators & tax assessors • Tobacco company executives • Decision-makers in marketing companies 

31. Unsafe Sex • Individuals (abstinence, fidelity, condoms) • Communities (norms regarding male dominance and multiple partners) • Poverty (transactional sex for poor women) • Health policymakers and health workers (effective AIDS prevention programs) 

32. Unsafe Water and Lack of Adequate Sanitation • Individuals (where they fetch water, boiling water, washing hands) • Communities (fatalism regarding diarrheal diseases, community latrines) • Governments (ignore or underfund safe water and sanitation needs)

33. Risky behaviorstranslate to diseases

34. Global Causes of Death Injuries Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies Noncommunicable diseases Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).

35. Behavior change reduces risky behaviors

36. Health Promotion Means Changing Behavior at Multiple Levels AIndividual: knowledge, attitudes, beliefs, personality  B Interpersonal: family, friends, peers  C Community: social networks, standards, norms  D Institutional: rules, policies, informal structures E Public Policy: local policies related to healthy practices Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at http://cancer.gov.

37. A: Individual-Oriented Models • Individual most basic unit of health promotion • Individual-level models components of broader-level theories and approaches • Models • Stages of Change Model • Health Belief Model

38. Stages of Change Model • Changing one’s behavior is a process, not an event • Individuals at different levels of change • Gear interventions to level of change Source: James O. Prochaska et al., “In Search of How People Change: Application to Addictive Behaviors,” American Psychologist 47, no. 9 (1992): 1102-14.

39. Stages of Change Model (cont.) Precontemplation Maintenance Contemplation Action Decision

40. Health Belief Model • Perceived susceptibility and severity of ill health • Perceived benefits and barriers to action • Cues to action • Self-efficacy  Source: Irwin M. Rosenstock et al., “Social Learning Theory and the Health Belief Model,” Health Education Quarterly 15, no. 2 (1988): 175-85.

41. B: Interpersonal Level:Social Learning Theory • Interaction of individual factors, social environment, and experience • Reciprocal dynamic • Observational learning • Capability of performing desired behavior • Perception of self-efficacy Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).

42. Interpersonal Level:Social Learning Theory (cont.) • Three strategies for increasing self-efficacy • Setting small, incremental goals • Behavioral contracting: specifying goals and rewards • Self-monitoring: feedback can reinforce determination to change (keep a diary) • Positive reinforcement: encouragement helps Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).

43. C: Community-Level Models • Analyze how social systems function • Mobilize communities, organizations, and policymakers • Use sound conceptual frameworks • Community Mobilization • Organizational Change • Diffusion of Innovations Theory

44. Community Mobilization • Encompasses wider social and political contexts • Community members assess health risks, take action • Encourages empowerment, building on cultural strengths and involving disenfranchised groups Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire, Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).

45. Define problem Identify solutions Initiate action Allocate resources Implement Institutionalize Organizational Change Organizational Stage Theory Organizational Development Theory Organizational structures Worker behavior and motivation

46. Diffusion of Innovations Theory • How new ideas, products, and behaviors become norms • All levels: individual, interpersonal, community, and organizational • Success determined by: nature of innovation, communication channels, adoption time, social system Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).

47. Diffusion of Innovations (cont.) Nature of innovation • Relative advantage over what is being replaced • Compatible with values of intended users • Easy to use • Opportunity to try innovation • Tangible benefits

48. Diffusion of Innovations (cont.) Communication channels • Mass media (enhanced by listening groups, call-in opportunities, and face-to-face approaches) • Peers • Respected leaders

49. Diffusion of Innovations (cont.) Adoption time • Awareness Intention Adoption Change • Gradual • Movement through groups • Pioneers • Early adopters • Masses

50. Diffusion of Innovations (cont.) Social system: • Identify influential networks to diffuse innovation: health systems, schools, religious and political groups, social clubs, unions, and informal associations • Identify opinion leaders, peers, and targeted media channels to diffuse innovations