'Well-being': health promotion's red herring

‘Well-being’ is frequently said to be the ultimategoal of health promotion. However, health promotion author itiesdo no: offer a clear definition of ‘well-being’.Instead health promoters either assume a causal relationshipbetween their activities and the increase of ‘well-being’or claim privileged knowledge of ‘well-being’ andits means of production, or both. These health promotion strategiesare questioned, and it is suggested that the use of ‘well-being’in health promotion acts to obscure the analysis of health promotionphilosophy and practice. It is concluded that either the term‘well-being’ should be given clear and substantialcontent, or it should be discarded by health promoters. Thelatter option is favoured.     

"Uncertainty" in health promotion: Nutriton policy in two countries

This paper presents a macro-analysis of the approaches chosenby Canada and Norway–two of the western developed countriesmost committed–to health promotion policy. In both countriesinnovative and diverging approaches to health promotion arecurrently being implemented. The analysis concentrates on an area highly related to healthpromotion, namely nutrition policy. The paper explores the rationalebehind the approaches to health promotion in Canada and in Norwayin the period 1973–83. It puts forward the notion of "uncertainty"and explores policy areas in which such uncertainty has beenoverlooked in the two countries.     

Lay theorizing about 'the body' and implications for health promotion

The body is central to our understanding and experience of health,illness and disease. In recent years it has also been a sitefor control and change through lifestyle directives. However,health promotion has yet to embrace the concept of human embodimentand the implications that this might have for practice. Thisneglect mirrors what has, until recently, been a failure ofsociology and anthropology to take the body seriously withinits own theorizing. Whilst at a theoretical level this has changed,there is still little empirical work on the body. This paperreports on findings from three independent qualitative researchprojects conducted in Scotland: health and health promotionin the middle years (45–59); the health beliefs of menaged 30–40; and the health beliefs of people with physicaldisability. All studies involved in-depth interviews with analysisbased on the grounded theory method. After presenting empiricalfindings on lay perceptions of the body as they relate to thenotion of personal responsibility for health, the paper goeson to address implications for health promotion—theoryand practice.     

Empowerment: A goal or a means for health promotion?

Empowerment is a concept that has been much used and discussed for a number of years. However, it is not always explicitly clarified what its central meaning is. The present paper intends to clarify what empowerment means, and relate it to the goals of health promotion. The paper starts with the claim that health-related quality of life is the ultimate general goal for health promotion, and continues by briefly presenting definitions of some central concepts: “welfare”, “health” and “quality of life”. Several suggestions as to what empowerment is are then discussed: autonomy, freedom, knowledge, self-esteem, self-confidence, and control over health or life. One conclusion of this discussion is that empowerment can be seen as a complex goal which includes aspects of the three central concepts welfare, health and quality of life. To the extent that the empowerment goals aimed at are health-related, it is concluded that empowerment is a legitimate goal for health promotion. But empowerment is not only a goal, it can also be described as a process or as an approach. This process, or approach, in a fundamental way involves the participants in problem formulation, decision making and action, which means that the experts have to relinquish some of their control and power.     

Integrated management of the sick child.

Diarrhoea, pneumonia, measles, malaria and malnutrition account for more than 70% of deaths and health facility visits among children under 5 years of age in developing countries. A number of programmes in WHO and UNICEF have developed an approach to the integrated management of the sick child, which is being coordinated by WHO''s Division for the Control of Diarrhoeal and Acute Respiratory Disease. Integrated clinical guidelines have been developed and a training course for health workers in outpatient (first level) health facilities has been completed. In addition to case management of these diseases, the course incorporates significant prevention of disease through promotion of breast-feeding, counselling to solve feeding problems, and immunization of sick children. Other materials to train and support health workers are also being developed: an inpatient case management training course, medical school curricular materials, a drug supply management course, and materials to support monitoring and reinforcement of skills after training. A planning guide for interventions to improve household management of childhood illness is also being developed. Since management of the sick child is a cost-effective health intervention, which has been estimated to have a large impact on the global burden of disease in developing countries, the completion of these materials and their wide implementation should have a substantial impact on child mortality.     

Creating empowering meaning: an interactive process of promoting health with chronically ill older Canadians

Many health promotion approaches afford education about disease prevention and enhancement of one's health status. But strategies for enabling older people with chronic illness to better mobilize their resources for everyday living still require development. This practical action research study explored the experiences of 13 purposefully selected older persons who participated in a health promotion intervention premised on the adult education theory of perspective transformation. Findings illuminate health promotion through a holistic interactive process in which professional and chronically ill older person together evolved a caring relationship and enhanced conscious awareness of life and health experiences. Five health-promoting strategies were identified: building trust and meaning; connecting; caring; mutual knowing; and mutual creating. Researchers suggest several important directions to refine professional practice approaches and health care delivery systems in order to promote the health of older persons with chronic conditions.     

Dilemmas of health promotion and political changes in Eastern Europe

Mortality and morbidity trends in the Western and the Easternparts of Europe have differed considerably during the past threedecades. The ‘socialist’ political regimes havebeen largely responsible for the deterioration of health ofthe population. The main features of this unfavourable situationcan be summarized as follows: low value set on man, on humanlife and health; extreme tensions between depressed living standards,aspirations and their gratification; negative effects of thereproduction of the social structure; chronic lack of genuinehuman communities, human relationships and social support, disordersof the value system. The author presents in case study the dilemmasthe Hungarian health promotion programme has to face. In the1990s in Eastern Europe health promotion has to face the followingchallenges: How is it possible to carry out effective preventiveactivities under circumstances of economic crisis, lack of resourcesand the population's declining living standards? What will bethe new responsibilities in prevention related to poverty, deprivationand unemployment? What will the new health care system be like?How should health be promoted in reorganizing local societies,communities? In the Eastern Europe of today, there is a greaterneed than ever before for health promotion.     

Health education and the ideology of health promotion: a review of alternative approaches

This paper discusses various approaches to the definition of‘health promotion’ and examines the role of theWorld Health Organization in its popularization. Health promotionis conceptualized as any deliberate intervention which seeksto promote health and prevent disease and disability. It incorporates‘health education’ and gives prominence to the influenceof legal, fiscal, economic and environmental measures on communityhealth. Various ‘models’ of health education areexplored and their contribution to health promotion is discussed.It is argued that ‘selfempowerment’ should be themain focus for health education programmes.     

Evaluation of preventive and health promotion activities in 166 primary care practices in Spain

BACKGROUND: Since January 1989 the Spanish Society of Family and CommunityMedicine has supported the Program of Prevention and HealthPromotion (PAPPS) with the following objectives: to detect possibledifficulties in the implementation of recommendations especiallyamong asymptomatic low-risk adults and children in Spain, todisseminate those recommendations, and to encourage researchin prevention and health promotion in primary care. OBJECTIVE: We wished to evaluate the implementation of PAPPS in primarycare practices. METHODS: A retrospective audit of medical records in practices enrolledin the programme was carried out. From 166 primary care practiceswidely distributed in Spain 21 631 patients were selected usingsystematic sampling. RESULTS: Age was positively associated with correct performance in theadult population, while in the paediatric population it wasnegatively associated. Females had a higher probability thanmales of having blood pressure measurement (OR 1.34, 95% Cl1.24–1.45) and smoking counselling (OR 1.38, 95% Cl 1.33–1.43)correctly performed. Practices not using the preventive charthad a lower probability than user practices of correctly performingblood pressure measurement (OR 0.69, 95% Cl 0.62–0.76),alcohol counselling (OR 0.66, 95% Cl 0.60–0.73) and smokingcounselling (OR 0.69, 95% Cl 0.63–0.76). Non-teachingpractices had a higher probability than teaching centres ofcorrect performance of blood pressure measurement (OR 1.47,95% Cl 1.35 to 1.59), alcohol counselling (OR 1.67, 95% Cl 1.54to 1.79) and smoking counselling (OR 1.39, 95% Cl 1.29 to 1.51). CONCLUSIONS: There is an unequal level of performance depending on the procedureand on the target population. A preventive chart might be usefulin improving implementation of periodic health maintenance.Teaching centres with training physicians need to put more emphasison prevention and health promotion activities. Keywords. Evaluation, health promotion, prevention, primary care.     

Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.     

Disease prevention and health promotion: a study of medical students and teachers

All students at the Royal Free Hospital School of Medicine (n = 508 ) were surveyed on their self-reported smoking and drinking habits, attitudes to disease prevention and health promotion in general, attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught at the beginning of the 1993–1994 academic year (response rate 75.2%). The teaching staff (n = 271 ) were also surveyed on their attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught (response rate 74.2%). Seventeen per cent of the students reported they were current smokers and 81% drank alcohol. Four factors were extracted from the responses to the items on disease prevention and health promotion in general and these represented the importance of health, a patient-centred approach, patient responsibility and a doctor-centred approach. Clinical students and those who were older were more likely to have a ‘patient-centred’ approach to disease prevention and health promotion. Sixty per cent of clinical and 44% of pre-clinical teachers aimed to teach about disease prevention and health promotion. The topics reported by students as most likely to have been taught in detail are smoking and health, alcohol and health, immunization, and breast and cervical screening. However, all these topics were reported as having been taught in detail by less than 50% of the students. The majority of students and teachers believe that teaching about disease prevention and health promotion should be integrated into all years of the curriculum and all clinical firms. Teachers were significantly less likely than students to believe that students should learn more about disease prevention and health promotion, and that learning about prevention is as important as learning about diagnosis and treatment. We believe that, in order to build on the positive features highlighted in this study, agreed aims and objectives should be developed and teaching about disease prevention and health promotion should be integrated both horizontally and vertically throughout the curriculum.     

The social image of smoking among young people in Scotland

This study aimed to gain an understanding of the contemporaryimages of smoking held by young people, the sources of suchimages, and their relationship to young people's social groupingsand smoking behaviour. It involved an in-depth qualitative investigationusing focus groups to elicit young people's ideas, attitudesand experiences of smoking. A total of 234 people from threeage groups (11–12, 13–15 and 16–20 years)participated in the study. Cigarette smoking was found to bepredominantly a social and group activity. It was also a behaviourabout which young people often held ambivalent and contradictoryattitudes, e.g. expressing both positive and negative imagesirrespective of whether or not they smoked. For many smokers,smoking was part of their social and cultural worlds, e.g. intheir group activities, or the focus of specific concerns suchas weight loss. Smokers often seemed to view their own behaviourand that of others differently. The research has implicationsfor health promotion, particularly the need to understand andaddress the meanings that young people attach to their behaviours,and acknowledge the ambivalence and contradictions in theirattitudes.     

Position of the American Dietetic Association: the role of nutrition in health promotion and disease prevention programs

A healthful diet and wise food choices are critical components of promoting health and reducing the risk of chronic disease. A substantial amount of health care resources could be saved by expanding health promotion and disease prevention programs that target dietary change among Americans. To effectively reduce health care costs, the emphasis and delivery of health care must promote health as well as deliver treatment and rehabilitative services to the sick. Prevention measures, such as nutrition interventions that also encourage physical activity, can help prevent or halt progression of full-blown chronic disease and thus decrease chronic disease disability. Health promotion and disease prevention need to be integral parts of all health care, community, public health, and worksite programs across the life cycle. Correspondingly, such programs must be culturally competent and address the specific needs of vulnerable or underserved populations. Dietetics professionals in all areas of practice should play an integral role in health promotion and disease prevention programs. Achieving this goal will require expansion of training programs and active learning by dietetics professionals that includes theory and practice in using team approaches, developing coalitions, and managing complex systems. Dietetics professionals also need to amplify their understanding of politics, administration, health care financing, and reimbursement. Attention must also be expanded to include social and behavioral sciences and to address program evaluation, outcomes, and cost-benefit and cost-effectiveness in nutrition-focused health promotion and disease prevention programs. Continued training in program development, research, and evaluation will help build the body of evidence that supports ongoing inclusion of prevention in a rapidly changing health care environment.     

Continuous quality improvement and health promotion: can CQI lead to better outcomes?

Canadian health promotion organizations currently face two pressures.First, is the desire of health promotion organizations to seekmethods which will help achieve health promotion goals. Second,external funders are increasingly likely to require that healthpromotion organizations adopt ‘quality’ procedures,such as Continuous Quality Improvement (CQI). This paper exploresa set of questions that assess the potential benefits of CQIwith respect to health promotion organizations. These questionsinclude: Is the philosophy of CQI compatible with health promotionprinciples, values and beliefs? Is CQI methodology and approachapplicable to health promotion? If there are no irresolvableconflicts between CQI and health promotion, will implementingCQI processes improve health promotion practice? In addition,the paper highlights several issues that health promotion needsto address before adopting CQI, including: the meaning and relevanceof concepts such as ‘customer’ and ‘customersatisfaction’, within the context of health promotion;and the heavy emphasis that CQI places on data that are measurableand quantifiable. While further exploration and documentationare required before definitive resolution of these issues, apreliminary overview indicates that CQI, with some modifications,is compatible with health promotion in at least some circumstancesand that, if these modifications are implemented, CQI couldhelp health promotion achieve its goals.     

Examining the General Practitioner's Role in Health Education: A Critical Review

Calnan M. Examining the general practitioner's role in healtheducation: a critical review. Family Practice1988; 5: 217–223. Recent international and national policy documents have placedgreat emphasis on health promotion programmes and one of thekey figures in these programmes has been the general practitionerand the primary health care team. This review, drawing mainlyon evidence from the United Kingdom, critically reviews therole of the general practitioner in health promotion and diseaseprevention. The first part of the paper examines the assumptionsin contemporary policy and outlines alternative roles for thegeneral practitioner in health education. The second part focuseson the social organization of the doctor-patient relationshipand its influence on health education, specifically examiningthe structure of the doctor-patient relationship, the uncertaintiesin scientific health knowledge and the lay perspective on health.     

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

OBJECTIVE: The aim of the study was to examine the effect of a computer-generatedpatient-held medical record summary (CHR) and/or a written personalhealth record (PHR) on patients' attitudes, knowledge and behaviourconcerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patientsaged 25–65 years in each practice were randomly assignedto receive either a CHR plus PHR, CHR only, PHR only, or nopersonal record. Patients were recruited by mail (one practice)or opportunistically by nurses (four practices). Health checkswere carried out using the randomly assigned record, which thepatient retained. Attitudes to patient-held records, and pre-and post-intervention knowledge and behaviour concerning healthpromotion, were assessed using questionnaires. Only those whoresponded to ‘before’ and ‘after’ questionnaireswere included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitmentand 103 from opportunistic nurse recruitment. Patients receivinga CHR as part of mail recruitment were significantly more likelyto attend for a health check (P = 0.016). Those receiving bothPHR and CHR were more likely to keep (P = 0.014) and use (P= 0.029) the record. Those receiving PHR as part of the packageimproved their knowledge of health promotion and became moreaware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held healthsummary and an explanatory booklet together is greater thaneither separately in changing patients' knowledge attitudesand behaviour concerning health promotion. Keywords. Patient-held record, primary care, health promotion, computerized medical record.     

Towards a framework for outcome assessment of health intervention: Conceptual and methodological considerations

We provide a framework for assessing the outcome of community-basedintervention programmes for the promotion of cardiovascularhealth at local level. Particular attention is therefore givento conceptual components connected with community participationin health programmes and to methodological approaches in theevaluation of cardiovascular disease (CVD)-prevention programmes.In a search of the literature covering more than 20 years (1966–1988)in 2 databases (MEDLINE and SOCA), we found that the conceptsof ‘community participation’ and ‘communityinvolvement’ have mainly been used during the latter halfof the study period. The concepts were often used interchangeablyand with no statement as to their precise meanings. The methodologicalexamination of 2 well-known community-based CVO-preventive programmesrevealed that most of the scientific papers from these programmesdealt with health behavioural and/or medical effects. The suggestedframework presented in this study is designed as a longitudinalprocess analysis focusing on critical key steps along the pathfrom input to output. The suggested research strategy is problem-orientated,inter-disciplinary and based on a multi-method approach.     

Predictors of changes in sick leave in workers with asthma: a follow-up study

Objective: The aim of this prospective study was to investigate predictors of 1-year changes in sick leave in workers with asthma. Methods: The initial cohort consisted of 111 workers with asthma. One-hundred and one participants completed the follow-up after 1 year. Self-reported sick leave over the past 12 months was reported at baseline and at follow-up. At the start of this study, all participants completed questionnaires on adaptation to functional limitations, psychosocial variables, working conditions, lung function characteristics, disease history characteristics, health complaints and functional limitations, and person characteristics (‘potential predictors’). Three multivariate logistic regression models were calculated, with an increase in sick leave, a decrease in sick leave, and stable high sick leave as dependent (outcome) variables, and the potential predictors as independent (explanatory) variables. Results: An increase in sick leave was predicted by a lower level of education and perceiving more functional limitations in activities of daily life. A decrease in sick leave was predicted by spending all energy at work less often and perceiving fewer health complaints in social activities (adaptation criteria 4 and 5). Stable high sick leave was predicted by less job satisfaction, perceiving more support from the employer and perceiving more health complaints in social activities (adaptation criterion 5). Lung function characteristics, or disease history characteristics were not predictive for changes in sick leave in any of the groups. Conclusion: We conclude that adaptation to functional limitations played a major role in changes in sick leave in workers with asthma. Lung function characteristics hardly played a role.     

Bureaucratic logic in new social movement clothing: the limits of health promotion research

This paper discusses theoretical, methodological and politicalproblems in the field of health promotion research. It arguesthat these problems result from a partial and contradictoryappropriation of the discourse of new social movements. Politically,the health promotion movement is largely confined within thestate, rather than the expression of a social movement againstthe state. The direction of health promotion research and policyis, therefore, caught in the bureaucratic logic of ‘trappedadministrators’, and results in contradictory emphaseson problems like the development of ‘health promotionindicators’, which show little result in informing a broaderbut coherent conceptualization of health, let alone in effectingchange in health policy and outcomes. Such political problemsreflect parallel confusions about theory and methodology. Theoretically, the field relies heavily on a critique of bio-medicalscience, but fails to move beyond a rhetorical outline of analternative to systematic arguments about what promotes health.In this regard, the literature on health promotion remains unawareof important conceptual developments in the social sciences,relies on imprecise specifications of major constructs likecommunity empowerment, and has no conception of the state. Methodologically,the literature is influenced by contradictory epistemologicaltendencies which reflect a positivist inspiration (as in thesearch for indicators) and an anti-positivist emphasis on agencyand social change through the collective action and the discursivereconstitution of social identity, value and meaning. In regardto these questions, this paper is critical of observers whosuggest that the way ahead is to embrace post-modern researchstrategies. Movement in this direction would tend to diffusean already desultory research practice and depoliticize socialstruggles for meaningful change. The paper ends by suggestingthat the field of health promotion needs a more serious engagementwith critical social theory to construct a rigorous conceptualizationof health and its social correlates and to develop a coherentresearch practice and political project.