The first World Health Organization (WHO) international conference on health promotion was held in Ottawa, Canada, in 1986. The outcome of this conference was the formulation of the Ottawa Charter for health promotion (WHO 1986, p.l). This conference was based on the progress made through the international Primary Health Care (PHC) conference, held in Alma Ata, 1978.The outcome of this PHC conference was the declaration of Alma Ata which contained the ten principles which were the blueprint for PHC. PHC was identified as a key to achieving an acceptable level of health for all the people of the world by the year 2000 (Wass 2000, p. 10). This was later known as "Health for all by the year 2000" (HFA) (Wass 2000, p. 10). In this declaration of Alma Ata one of the recommendations was that PHC should address the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly (WHO 1978, p.l).
The goals and targets for HFA, as identified in Alma Ata, were to achieve an increase in life expectancy and in the quality of life for all, and also to implement measures to promote health.
According to the WHO (1997, p.l), HFA focused on action to be taken to address the determinants of health and to promote health in all settings. Hence, the Ottawa Charter for health promotion set out the action required to achieve the HFA.
The concept of health promotion was defined in the Ottawa conference. Health promotion was defined as "the process of enabling people to increase control over, and to improve, their health"
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(WHO 1986, p i ) . Since this conference, different authors in the health field and even outside the health field, such as in the field of psychology, have debated the meaning of the concept of health promotion\ There are many differing views on what health promotion is. The most prominent ones that can be identified are (a) those that are purely based on the original definition of health
promotion as defined in the Ottawa conference; (b) the ones that view health promotion in relation to behavioural change; (c) health promotion as covering health protection and health education;(d) as related to primary health care and community health nursing (e) health promotion in the context of
"marketing" and (f) health promotion in the context of empowerment.
In their concept analysis, Maben and Macleod -Clark (1995) proposed that health promotion be defined as "an attempt to improve the health status of an individual or community, and is also concerned with the prevention of diseases" (p. 1163). In this context, health promotion is viewed as attempts to improve the health of an individual or community and is concerned with prevention of disease. Health promotion is concerned with people and their well-being, but from their own perspective (Raeburn 1992, cited in King 1994, p. 209).
Authors such as Clark (1996, 10) and Flynn & Krothe, cited in Stanhope and Lancaster (1996 p.239), are of the opinion that health promotion is the first level of care that involves activities designed to improve or maintain health status, also that it should be considered as one of the tools for achieving primary health care (PHC), and that it focuses on disease prevention. This view is disputed by others, since they argue that, although health promotion is an important tool in primary prevention, which is the focus in primary health care delivery; these two concepts are different
(Nutbeam 1986, p. 25; Pender 1987, p. 6; Whitelaw 1997, p. 60 & King 1994, p. 212). These authors
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are in agreement that even though these terms are different they are complementary activities, which overlap in a variety of situations and circumstances.
Nutbeam (1986), cited in Dines and Cribb (1997, p. 25), distinguishes between the two concepts by first looking at their aims. For this author, disease prevention aims to conserve health and focuses on the selected individuals or groups, health promotion on the other hand, aims to enhance health and starts out with the whole population in the context of their every day lives. This differentiation is echoed by Dines and Cribb (1997, p.25) where they maintain that disease prevention is part of health promotion because if health is to be enhanced this must include its conservation, but they further argue that health promotion begins with people who are basically healthy and seeks the development of community and individual measures. Pender's (1987, p. 6) explanation of the two terms is that health promotion is not disease specific whereas disease/illness prevention is.
Other authors prefer to portray health promotion as an umbrella term, which includes any activity designed to foster health. These authors' understanding is that health promotion needs to be viewed as an umbrella under which any health service may find coverage (Tones, Tilford & Robinson et. al.
1990, p. 18; Duncan & Gold 1986, cited in King 1994, p.212). Denis et al. (1982), cited in Dines and Cribb (1997, p.), are also in agreement with this view, and further assert that health promotion includes all those activities that seek to improve the health status of an individual and the
communities. This understanding of health promotion seems to be too broad. It draws attention to an argument raised by Maben and Macleod (1997, p. 1159), when they questioned whether health promotion could be equated to health promotion plus health education or whether these two terms can be used interchangeably.
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Maben and Macleod (1997, p. 1160), argue that these two terms cannot be equated but are
complementary, as health promotion should be equated to health education plus information giving, life skill teaching, self empowerment and promotion of health through social environment measures.
Health education should be seen as an essential prerequisite, in the delivery of all health promotion programs (Huiskamp 2003, p. 56).
Health promotion and health education, even though they are not similar, go hand in hand but health promotion should also include other factors such as environmental, organizational and economic
factors (Green 1987, cited in Norton 1998; Tones et al. 1990). These authors suggest that these factors are also very important in the successful implementation of health promotion programs. The significance of these factors is also supported by the Ottawa Charter components, that is, health promotion should mean, among other things, creating supportive environments, and building health policies (WHO 1986). Pender (1987, p.7) echoes this declaration and states that the health of individuals and families is affected markedly by the community, environment and the society in which they live. The approach in health promotion should therefore focus mainly on the
environments where individuals live.
HEALTH PROMOTION, WELLNESS AND WELLBEING
The three concepts health promotion, wellness and wellbeing are sometimes used interchangeably in literature with regard to workplace health interventions. These concepts have, however, been
conceptualised differently by professionals and practitioners in different fields. Health promotion, as conceptualised in the abovementioned literature review, aims to help people to change their lifestyle to move towards a state of optimal health. Wellness, on the other hand, has been defined as "a set of organised and systematic interventions, offered through corporations/worksites, managed care
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organisations, and governmental/community agencies, whose primary purposes are to provide health education, identify modifiable health risks, and influence health behaviour" (Mulvihill 2003, p. 13).
Other authors have argued that in defining wellness, attributes such that it is based on individual choices about their own lives and priorities that determine their own lifestyles should be added (Arizona State University 2000, p i ) .
The concept of wellbeing has been defined in terms of physical, emotional, mental and social wellbeing which includes workplace alcohol use. There appears to be a link between physical and emotional wellbeing, with emotional distress from life events creating susceptibility to physical illnesses, such as cardiovascular disease (McAllister 2005, p.9). Wellbeing programs therefore need to focus on all these areas. For example, health interventions focusing on social and emotional support can contribute in reducing or preventing illness and reducing disease. Health promotion programs therefore need to be operationaUsed to indicate the level they are in or a combination of all these programs can be offered as comprehensive workplace health interventions.
HEALTH PROMOTION THEORIES AND MODELS
Different authors have classified the models and theories that are commonly used in health
promotion to different, yet linked, classifications. The first classification of health promotion models classifies them according to their use in health promotion programs, namely:
(a) Planning models, such as the PROCEDE- PRECEDE model (Green & Kreuter 1991),
(b) Evaluation models such as Nutbeam's outcome model for health promotion (Nutbeam 2000), and (c) Stages of change/Transtheoretical model (Prochascha & DiClemente 1983).
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Table 2 . 1 : Common models and theories used in health promotion (Adapted from National Institutes of Health, 1995, p. 3; National Centre for Chronic Disease Prevention and Promotion, 2003, p. 1)
Level
Individual level
Interpersonal level
Community
level/Organizational level
Theory/Model Health Belief Model
Stages of change (Transtheoretical model)
Social learning theory (Social cognitive theory)
Theory of reasoned action
Community organization theories
Organizational change theory
Focus
Person's perceptions of the threat of a health problem and the appraisal of recommended behaviour (s) for preventing or managing the problem.
Individual's readiness to change or attempt to change toward healthy behaviour.
Health behavioural change is a result of reciprocal relationships in which personal factors;
environmental influences and attributes of behaviour interact.
Self-efficacy is one of the important characteristics that determine behavioural change.
For behaviours that are within the person's control, behavioural intentions predict actual behaviour.
Intentions are determined by attitude towards the behaviour and beliefs regarding other people's support of the behaviour.
Emphasize active participation and development of communities that can better evaluate and solve health social problems.
Concerns processes and strategies for increasing the chances that healthy policies and programs will be adopted and maintained in formal organizations.
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