(a) Building healthy public policy
Health promotion puts health on the agenda of policymakers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.
(b) Creating a supportive environment
Changing patterns of life, work and leisure have a significant impact on health. Work and leisure should be a source of health for people. The way that society organizes work should help create a healthy society. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable.
(c) Strengthening community actions
Health promotion works through concrete and effective community action at setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is empowerment of communities, their ownership and control of their own endeavours and destinies.
(d) Developing personal skills
Health promotion supports personal and social development through providing information, education for health and enhancing life skills. It increases the options available to people to exercise more control over their own health and over their environments and to make choices conducive to health.
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(e) Reorienting Health Services
The role of the health sector must move increasingly in a health promoting direction, beyond its responsibility to provide clinical and curative services. Health services need to embrace an expanded mandate, which is sensitive, and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between health sector and broader social, political, economic and physical environment component. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This reorientation must lead to a change of attitude and organization of health services, which focus on the total needs of the individual as a whole person.
DIFFERENT APPROACHES TO HEALTH PROMOTION
Contemporary health promotion has a few health promotion approaches that have been introduced to implement health promotion programs.
Medical/Preventative Model
This is perceived as a traditional approach in health promotion and remains the most popular (Naidoo & Wills 2000, p. 92). This approach focuses on disease, medical interventions and medical explanations of health (Ewles & Simnett 1995, p . ) . It is directed at improving
decreasing physiological risk factors, such as high blood pressure (Act community care 2006).
These authors maintain that the medical/preventive approach promotes health through the following:
Preventing the initial occurrence of an illness (primary prevention),
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Stopping or slowing existing illness (secondary prevention),
Reducing the re-occurrence and establishment of the chronic illness (tertiary prevention).
This approach has been criticised for its narrow concept of disease and because it ignores social/environmental dimensions, such as immunizations and screening (t & Simnet, 1995).
Educational Approach
According to Naidoo & Wills (2000), the educational approach aims at providing advice and information to the individuals so that they can make informed choices. In this approach, clients are given health education about the illness and it is up to them to decide on taking an action or not. It is widely used in giving health education in schools.
Social Change
This model is also known as the socio-environmental approach. It is a radical health promotion approach, which focuses on the socio-economic environment in determining health (Ewles &
Simnett 1995). The assumption in this approach is that health is not just about prevention of disease and increasing longevity, but is also concerned with maximising well being (Naidoo and Wills 1998). This approach promotes health by addressing the broader social determinants of health as well as creating healthy environments
(http://www.healthpromotion.act.gov.au/whatis/basics/approaches.htm). This approach is therefore commonly used in actions focusing on creating healthy environments, working with the community to strengthen healthy environments and advocating public policy, since these are part of health promotion as identified in the Ottawa Charter.
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Table 2.2: Approaches to health promotion (Adapted from Ewles & Simnett, 1995) Approach
Medical
Behaviour Change (lifestyle change)
Educational
Client centred (Empowerment)
Societal change (socio-
environmental approach)
Aim
Freedom from medically defined disease and disability
Individual behaviour conducive to freedom from disease
Individuals with knowledge and
understanding enabling well informed decisions to be made and acted upon.
Working with the clients on the clients' own terms.
Physical and social environment which enables choices of healthier lifestyle
Health Promotion Activity
Promotion of medical intervention to prevent or ameliorate ill-health
Attitude and behaviour change to encourage adoption of'healthier' lifestyle
Information about the cause and effects of health- demoting effects of health - demoting factors.
Exploration of values and attitudes.
Development of skills required for healthy living.
Working with health issues, choices and actions which clients identify. Empowering the client.
Political/social action to change physical/social environment
Important Values Patient
compliance with preventive medical procedures
Healthy lifestyle as defined by health promoter
Individual right of free choice.
Health promoter's responsibility to identify
educational content.
Client as equal.
Client's right to set agenda. Self- empowerment of client.
Right and need to make
environment health-enhancing
Example: Smoking Aim: freedom from lung disease, heart disease and other smoking related disorders.
Activity: Encourage people to seek early detection and treatment of smoking-related disorders.
Aim: behaviour changes from smoking to non- smoking.
Activity: persuasive education to prevent non-smokers from starting and persuade smokers to stop.
Aim: clients will have understanding of the effects of smoking on health. They will make a decision whether or not to smoke and act on that decision.
Activity: giving information to clients about the effects of smoking. Helping them to explore their own values and attitudes and come to a decision.
Helping them to learn how to stop smoking if they want to.
Aim: anti- smoking issue is only considered if clients identify it as a concern.
Activity: clients identify what, if anything, they want to know about it.
Aim: make smoking socially unacceptable, so it is easier not to smoke than to smoke.
Activity: no smoking policy in public places.
Cigarette sales less accessible, especially to children, promotion of non-smoking as a social norm. Banning tobacco advertising and sports sponsorship.
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Behaviour Change/Lifestyle Approach
According to Naidoo and Wills (2000), this approach aims to persuade individuals and groups to change their health behaviour and adopt a healthy lifestyle. It is based on a belief that giving people knowledge and skills to adopt a healthy lifestyle will improve their health. It commonly focuses on an individual or population level and uses strategies such as health education, social marketing, self-help, self-care and public policies to support a healthy lifestyle. Stop smoking campaigns' are mostly based on this approach
(http://www.healthpromotion.act.gov.au/whatis/basics/approaches.htm). This approach has been criticized for assuming that unhealthy behaviour such as smoking is a freely chosen individual behaviour, thereby ignoring other social determinants such as social class, ethnicity and income.
Empowerment Approach
Naidoo and Wills (2000) refer to this approach as the one that assists people in identifying their health concerns and in developing skills to act upon these. The health educator acts as a
facilitator (Ewles & Simnett 1995). This approach focuses on self and community development (Naidoo & Wills, 2000; Ewles & Simnett 1995).
Empowerment includes enabling people to recognise their strengths, abilities and personal power (Mason et al. 1991, in Rodwel 1996, p307). This approach will parallel the social change approach and settings approach in that it also emphasises the significance and
availability of environmental resources in order for people to achieve health (Jones & Meleis
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1993, p. 8). These authors argue that the process of empowerment incorporates environmental as well as individual change, through sharing of resources and collaboration. This means that the environment should be supportive and the attitude of management to employee
participation in health programs should be positive, in order to enhance the process of empowerment (Hagquist & Starrin 1997, p 230). Empowerment in health promotion
interventions increases people's ability to identify their health needs and take control of their health. The empowerment approach requires that the health promoter adopt a role of a facilitator and resource person. This makes this approach also complement the behaviour change approach.
This is a more appropriate approach in workplace health promotion because it attempts to involve the important components of health promotion namely, individual behaviour, the environment and resources, and increasing people's abilities.
Settings Approach to Health Promotion
After the Ottawa conference on health promotion, the fourth international conference on health promotion was held in Jakarta, in 1997. This conference resulted in the Jakarta declaration on leading health promotion to the 21s t century (WHO 1997). What was significant about this conference was that for the first time, the health promotion conference was held in a
developing country and that it was the first to involve the private sector in supporting health promotion. One of the elements that came out of this conference was that particular settings offer practical opportunities for the implementation of comprehensive strategies. These settings included mega cities, islands, cities, municipalities, local communities, markets, schools, the workplace and health care facilities (WHO 1997).
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The settings approach to health promotion is hence based on the Jakarta declaration. Settings approach to health promotion means "practising health promotion in settings where people live and work, including home, school, workplace, hospitals, sporting and social setting" (Cullen 2003, p. 1). According to the WHO (1986), the workplace is a very important setting in achieving health promotion and health for all. WHO (1988) further argued that there is an interaction between the individual's health and his work. This makes the work environment the most important setting for health promotion. The working environment may influence the individual either positively or negatively and this will affect the individual's productivity at work since his mental or physical well being depends on his state of health (WHO 1988). For this reason it is imperative that workplaces establish a health institutional policy as the basis of institutional health promotion (Wass 2000, p. 175).
Chu et al. (2000) depict workplace as one of the most important settings affecting the physical, mental, economic and social well being of workers and the health of their families,
communities and society.
Furthermore, these authors believe that the workplace offers an ideal setting and infrastructure to support the promotion of health of a large audience. Huiskamp, King and Hattingh (2002) are in agreement with this argument and have also asserted that health promotion in the workplace is an integral part of the modern and contemporary management of the workplace and occupational health and safety. These authors further argue that the workplace is seen as an effective setting for health promotion because a great number of people can be reached and this
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working population can be in turn be role models to their families and friends. Health promotion in the workplace is therefore effective for economical and population reasons.
Chu et al. (2000) firmly believe that the concept of a health promoting workplace is becoming more significant and more relevant in the contemporary workplace, as more private and public organizations recognise that the success in an increasingly globalised marketplace can be realised with a healthy, qualified and motivated workforce. The latest approaches to health promotion in the workplace increasingly address both individual risk factors and organizational and environmental issues (Chu et al. 2000). This approach is better than earlier approaches, which focused mostly on individual wellness programs and ignored the organization as an environment wherein individuals interacted, and also proves to be in line with the Ottawa Charter strategies.
The National steering committee for health promotion in the workplace (1998) have defined workplace health promotion as "those educational, organizational and economic activities that are designed to improve the health of workers and therefore the community at large. This type of health promotion involves workers and management participating on a voluntary basis in the implementation of jointly agreed concepts. This committee further argues that health-
promoting programs in the workplace are distinct and separate from the responsibilities which employers have in the implementation of proper occupational health and safety measures in the workplace.
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Cowley and Billings (1999) elucidated that effective health promotion means providing appropriate resources to facilitate activities designed to improve well being. He implies that a supportive management is required to enhance the health promotion program in the workplace.
Chu et al. (2000) are in agreement this with argument but they are perturbed by the fact that workplace health promotion activities have been dominated by wellness programs which focus largely on an individual.
Such interventions, these authors argue, focused on such interventions as health screening, stress management courses, nutritional foodstuff in canteens, exercise and back care programs and health information seminars. These authors believe that workplace health promotion should be reoriented and be more holistic in approach, to address both individual risk factors and the broader organizational environmental issues. This attitude is in accord with the Ottawa charter for health promotion strategies, which put an emphasis on reorienting health services.
This reorientation should also, however, incorporate building healthy public policies.
Occupational health and safety programs need to focus on the enhancement of health promotion strategies within the organization, particularly those that require policy change.
According to Schmitz, in Sol and Wilson (1989) a comprehensive workplace health program consists of three levels, namely, (a) awareness which involves educational opportunities that prepare an individual to change behaviour, (b) behaviour change, which involves additional
educational opportunities (c) supportive environments are linked to behaviour change, in that if the behaviour change occurs in a supportive environment, that change is most likely to occur and be maintained.
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Based on the settings approach, the hospital as an institution can also be considered as a workplace. Maben and Macleod-Clark (1987) argued that the hospital has workers, patients and relatives and therefore can be a good setting for health promotion. Health professionals are expected to act as role models for their clients in all aspects, including health promotion
activities. Pender (1987) has raised an argument that the responsibility that health personnel assume for the care of others, their knowledge of health, is often not applied to their personal lifestyles. Pender believes that health promotion in hospitals, aimed at health care providers, can improve the role modelling capabilities of health professionals. Hope, Keller & O'Connor (1998) view the nurse professional as a key player in promoting change at a personal level, as role model, as a health promoter and as a professional carer.
Literature reveals that little research has been conducted on the impact of wellness programs on behaviours and lifestyle of hospital employees or on their viability as healthy role models for the patient population. The findings of the study conducted by Prendergast (1992), cited in Hope, Keller, and O'Connor (1998), revealed that public health nurses had healthier lifestyles than their hospital based counterparts. Stress in the nursing profession is widespread, with the workplace as a major stress source for nurses. This can be linked to the work itself, the role of the nurses, career prospects and organizational structures and concern about HIV/AIDS (Dionne, Proulx & Pepin 1993). Pender (1987) recommended that the focus of health
promotion in the hospital setting should be on nutrition, weight control, stress management and fitness.
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