Health education and health promotion - an ...

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THE concepts of 'health education' and 'health pro- motion' provide the underlying philosophy or foun- dation to the practices of the health educator. Health.
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Health education and health promotion - an Australian perspective K. John Fisher Lecturer, Department of Health Education & Adminstration Peter A. Howat Head, Department of Health Education & Adminstration Colin W. Binns Head, School of Community Health Mark Liveris Associate Director, Division of Health Sciences Western Australian Institute of Technology THE concepts of 'health education' and 'health promotion' provide the underlying philosophy or foundation to the practices of the health educator. Health education, it is asserted, involves activities which facilitate voluntry adaptations to behaviour. Health promotion, on the other hand, includes health education as an essential component, but can also involve other organisational, political and economic interventions which lead to improved health. Finally, health promotion initiatives are most effective when they are utilised in conjunction with health protection and health services initiatives. These latter three concepts form a triad that constitutes 'health enhancement'

SOME health professionals engaged in health education appear to cast aside theoretical or philosophical debate on the relationship of health education to health promotion in favour of more pragmatic or immediate issues.u Their undeniable privilege to ignore issues of definition or policy is not in question. Open debate, clarification and constant review of the underlying principles and practices of health education, however. are fundamental to the evolution of the discipline. For every setting in which health educators operate, each has a role to play in the development of the discipline. Within this context, the academic's task of provoking debate on philosophical issues holds equal weighting with the practitioner's task of alleviating health concerns in schools or in the community. The fact that philosophical debate hold serious implications for practitioners needs no further justification than by referring to the effects health promotion is having on the role of health education officers in Britain, Australia and other countries. 2·3 It is a concern which needs to be addressed.

Introduction The continuing concern among health educators

about the confusion between 'health education' and 'health promotion' begs for some degree of clarification as to the place, purpose and functions of the two concepts. In addition to Britain, this concern is expressed in the USA and in Australia 4 ·5 Why should we worry about the similarities and differences between health education and health promotion? What does it matter? This paper attempts to clarify the relationship between health education and health promotion from an Australian perspective.

Concepts of health promotion and health education Health education

A widely used definition of health education is: " ... any combination of learning opportunities designed to facilitate voluntary adaptations of behavior (in individuals, groups or communities) conducive to health" 6 Green's definition above lends itself to wide interpretation but the following points can be made: e health education has an individual and a social focus. e health education consists of any combination of learning opportunities- these can include informal methods. e health education is about voluntary changes in behaviour, although it does not deny that there are forces other than those under the control of individuals that influence behaviour. Health education can also be regarded as: the communication of knowledge and the provision of experiences to help individuals develop attitudes and skills, which will assist their adopting behaviour to improve and maintain health for themselves and their fellows. Health education aims to assist individuals, groups and communities to make informed decisions about their health. In addition, health education aims to enable individuals and groups to influence change in social policy7 According to this concept, health education aims first at encouraging individuals and communities to improve their own health-related behaviours. Second, health education includes activities that contribute to improving the living and working conditions of people through political initiatives and environmental changes. Thus, a health educated person understands those factors influencing his or her own health and the health of his or her family and community, and knows what needs to be done to improve the social context in which those factors operate. Both definitions involve individuals or groups in making voluntary decisions to improve health. Implied here is the fact that as knowledge expands, health education takes on new meanings and new directions.

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The levels of health education

Health education is a multidisciplinary activity involving a variety of purposes, methods and channels of delivery. The purposes can be conveniently categorised into three levels: primary prevention, secondary prevention, and tertiary prevention 8

Primary prevention Primary level health eduation aims to help individuals or groups learn how to keep healthy and how to prevent the onset of disease and disability. Schools . are seen as a prime location for primary prevention and risk reduction programmes, along with industry and the community. Health education for primary prevention encourages people to develop behaviour conducive to good health. Primary prevention is the level at which health education is able to encompass its role and function not only to influence individual behaviour change but also to influence group and community action to alter environmental, economic and organisational supports for health. Convincing authorities that fluoride reduces dental caries; and that the use of seat belts reduces the road toll, are examples of how health education can lead to important social changes. The authors argue elsewhere that health education aimed at changes in the social context, or 'structural perspectives', ought to be given at least equal emphasis to those behavioural perspectives aimed at selfresponsibility. 9

Secondary prevention Secondary level health education aims to assist individuals to recognise symptoms of diseases, and by identifying the early onset of illness, to enable them to seek measures to reverse or control the problem. The most common locations for secondary level health education are clinics, the community and, to a lesser extent, schools. Secondary prevention helps to reduce the prevalence of morbidity by shortening the duration of illness or by reducing the prevalence of screening occurring in the pre-morbid phase of disease.

Tertiary prevention Tertiary level health education is generally regarded as self-care education or patient education. The target groups are people with identifiable diseases, illnesses and injuries. Many of these conditions can be treated or controlled through personal and family self-care, independent of professional medical sources. The main purpose of tertiary health education is to help people learn about their illnesses, treatments and available health services, so that there is a reduced chance of recurrences or relapses. There is thus a reduction in the level of social and physical disability due to the sequelae of illness. Health promotion

There have been numerous attempts at defining health promotion in recent years. Essentially, concepts of health promotion fall into two distinct categories - enhancement of health solely via behavioural endeavours, or enhancement of health via a combination of endeavours. Chief among the pro-

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tagonists of a combination of endeavours is Lawrence Green 10 Others include Beard, 11 Catford and Nutbeam, 12 Davidson et al, 13 Iverson, 14 and Tones. 15 Protagnists of the mainly 'behavioural' perspective of health promotion include Rubinson and Alles, 16 Currie and Beasley, 17 and Seymour. 13 A widely used definition of health promotion is: . health education and related organisational, political and economic interventions that are designed to facilitate behavioural and environmental changes to improve health. " 19 A problem with this definition of health promotion is that it can be interpreted very broadly to encompass almost all interventions that are conducive to health. The term 'health promotion', as used here, could therefore be regarded as synonymous with the term 'public health'. However. a more recent, revised version of the definition of health promotion restricts it specifically to interventions that lead to changes in behaviour conducive to health, viz: "any combination of health education and related organisational, economic and environmental supports for individual, group and community behaviour conducive to health.' ' 20 Health education is just one component, but nevertheless an essential part of health promotion. Health promotion occurs when changes take place in the organisational, economic, or environmental milieux which support the adoption of positive health-related behaviours. Health education is generally an integral part of the process that leads to those changes. Other considerations in determining similarities and differences include the following: • health education is always health promotion, whichever methods are employed (individual approaches, group methods, mass media), or at whichever level it functions (primary, secondary or tertiary level). • the emphasis of health promotion is mainly on primary prevention, though it does embrace secondary and tertiary prevention as well. • health promotion endeavours can often involve mandatory changes in behaviour rather than just voluntary changes, for example, laws, and regulations. Health Promotion: One component of health enhancement In addition to health promotion, two other com-

ponents complete the triad of components which support initiatives conducive to health. These are health services and health protection. (Figure 1). Health services are resources and services provided by health organisations which contribute to health maintenance. Examples include immunisation services. high blood pressure screening, child health clinics, sexually transmitted disease clinics. Aids clinics. and family planning services. Health protection refers to regulatory procedures such as legislation, regulations. and standards which protect people from hazards to health. These initiatives involve changes to the environment. Examples include engineering standards, safety regulations, and toxic agent control.

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Figure 1. Components of health enhancement (modified from Green, 1984)21 Components of Health Enhancement

Change Processes

Changes conducive to health

Health Services

Organising resources

Access to services

- - - - - - - - -1 I

HEALTH EDUCATION

I I I I ~

I I I

i l Predisposing, enabling Health Promotion

Behaviour changes

and reinforcing factors

i t

I

--------_I

Health Protection

HEALTH STATUS

Regulations

These three components exist in a state of dynamic synergy, each with essential contributions to make to health enhancement, but whose combined influences are more effective than if the individual components are applied independently. When does health education become health promotion?

Health education is always health promotion in the sense that it is an essential part of it. Many would argue that health education is a precursor to health promotion. Health education is certainly more effective if it is supported and accompanied by other initiatives which bring about changes in behaviour and improvements in health. Confusion between the concepts of health education and health promotion often arise when health education at the primary level seeks to bring about changes in social or environmental factors which influence behaviour. When is health promotion not health education?

Some health promotion initiatives (such as the creation of smoke-free zones, and seat-belt legislation) are obviously not specifically designed learning opportunities; hence they cannot be regarded as health education. A good deal of health education may have preceded such initiatives, but once the health initiative or incentive has been enacted, commissioned or set in motion, it ceases to be health education. Other examples of health promotion initiatives which are not health education include: • increased funding for cycle-ways, public open space and recreation facilities; • changes in school or worksite canteen policies towards more nutritious items for sale; • the taxing of ill-health producing products such as cigarettes and alcohol; • drink-driving legislation; • controlling advertising of alcoholic beverages; • the provision of exercise facilities in the workplace; • actions by employers, unions, and government to reduce stress-creating work environments 22

Environmental changes

All these qualify as health promotion in that they support behaviour conducive to health, but not as

health education in that they are not specifically designed learning oportunities nor do they necessarily provide for voluntary changes in behaviour.

Summary The concept of health education has broadened in recent years to include a range of educational activities designed, not only to improve the health behaviour of individuals, but to improve living and working conditions via legislative and environmental changes. Health promotion (including changes in the environmental, economic or organisational factors which support behaviour conducive to improved health), is most often the result of effective health education. Some health promotion endeavours can be mandatory, while all health education endeavours are voluntary. Health education is an integral part of any health promotion endeavour aimed at improving the quality of life, and can be seen as an essential precursor to those improvements. Acknowledgements Acknowledgement is made to Professor Lawrence Green, Director, Centre for Health Promotion Research and Development, The University of Texas, Health Science Center at Houston, for his helpful suggestions.

References 1.

2. 3. 4. 5. 6.

McKeown KM. Action not words. Health Education Journal. 1984, 43 (4): 127. Seymour H. Health Education versus health promotion - a practitioner's view. Health Education Journal. 1984; 43 (2 & 3): 37-38. Catford C, Nutbeam D. Towards a definition of health education and health promotion. Health Education Journa/.1984; 43 (2 & 3): 38 Carylon WN. Disease prevention/health promotion Bridging the gap to wellness. Health values. Achieving High Level Wellness. 1984: 8 (3): May-June Howat PA, Fisher KJ. Health education for self-responsibility or health education for structural perspectives. ACHPER National Journal. June 5-9. 1984; 5-9. Green LW. Health promotion policy and the placement of responsibility for personal health care. Family and Community Health 1979(a); 2 (3): 51-63.

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7. 8. 9. 10. 11. 12. 13. 14.

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ANZAAS Conference. Health Education Section Perth

Howat PA Fisher KJ. Professwnal studies in health promotion and IJ('alth education at WAIT. Perth: Western Australian Institute of Technology, Publication 22920-2-85. 1985. Watts AC, Briendel CL. Health education: structural vs behavioural perspectives. Health Policy and Education. 1981: 2: 45-47. Howat PA Fisher KJ. 1985. op.cit. Green LW. How to evaluate health promotiOn. Hospitals. 1979(b); October 1 106-108. Beard T. Promotmg health: prospects for better health throughout Australia. Canberra: Australian Government Publishing Service. 1979. Catford C, Nutbeam D. 1984, op.cit. Davidson L. et al. Health promotion in Australia 1978-79. Canberra: Australian Publishing Service. 1979. Iverson D. A national health promotion programme for Australia: the role of the Government and the individual in Howat, P. A, Bunbury, J.. and Fisher. K. J. (Eds) Proceedings of 53rd

15. 16. 17. 18. 19. 20. 21. 22.

May 16-20. 1983. Tones K. Education and health promotion: new direction. Journal of the Institute of Health Education. 1984; 21: 121129. Rubinson L. Alles W. Health education: foundations for the Future. St. Louis: Mosby. 1984. Currie B, Beasley J. in Taylor. Ureda and Denham. Health Promotion. pnnciples and clinical application. Connecticut: Appleton Century-Crofts. 1980. Seymour H. 1984. op.cit. Green LW. 1979(b). op.cit. Green LW. Modifying and developing health behaviour, Annual Reviews of Public Health. 1984: 5: 215-36. tbid. Department of Health and Human Services. Promoting health. preventing disease: Objectives for the Nation.

Washington D.C.: U.S. Government Printing Office. 1980.

LETTERS

Reviewing the reviewer Dear Sir We are writing to take issue with you over the comments made by your reviewer m Vol. 45 No. 1 of the Journal about the Finding Out series of books. The teachers involved in writing the three books mentioned in the review were sent a copy of it and asked to submit their comments, of which this letter is a summary. Firstly, some general remarks. The reviewer seems to think the Finding Out books are presented as a gospel for schools, and as such are intended· to be authoritative and comprehensive in every detail. No such claim has ever been made; they are simply written by teachE:Jrs for teachers. Is Ms Ineson not losing. sight of the real aim.of the series - to ease the teachers' job of stimulating debate about contraversial issues in the classroom? · She is quite correct in her assertion that in. order .to "understand and resist the pressures which result.in their leading unhealthy lives in the shadow of nuclear anHihilation they (children) need critical and open discussion·' .It. is, however, quite ridiculous of her to suggest that our serieso( books ''is more likely to stifle real understanding''. Let the ·. facts speaks for themselves. In these days oflimited funds no teacher will buy materials that are ·noYliseful. How, then. does Ms Ineson explain the quite extraordinary popularity of the booklets and the fact that in their first year of publication, many thousand copies of them/were sold? Now to some more specific points. Why does the reviewer. under the aegis ofwhat is presumably intended to be a fair and unbiased reyi~w. contort what is actually found in the booklets to suit•rler own ends? We refer to what she calls the "euphemistic gem" in Finding Out About Nuclear Energy, "Civil and military plutonium cycles can be completely separate" and she adds the comment ("pigs might fly"), when in fact what she should have added is the first of

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what are two statements in a For and Against argument which reads 'Reactors produce plutonium which can be used to make more and more nuclear weapons'. Quoting the second part without the first is misleading to say the least. In a similar way, she claims that Finding Out About Medicines and Drugs is "relentlessly pro-drugs", which is quite simply untrue. It fills a gaping hole in health education material at 1;hfs level and, like the Smoking booklet, aims to provide information about individual tactics with regard to health. • With regard to the third booklet, Finding Out About Smoking, the whole issue of tobacco and advertising is far too complex to be tackled in one short booklet. As tobacco is the third largest source of revenue to the present UK Government. the politics are complicated and not to be taken lightly. Surely the reviewer would agree that it is extremely difficult for students to engage with topics which are outside their own experience and, therefore, an individual approach, rather than a deeper examination cif the subject, h?s considerable currency, especially in the earlier stages of a cQ_urse of study. In'~;;;pnclusion. one cannot help but wonder whether Antonia eson does not have preconceived ideas about what sho . be happening to health-related issues like smoking, drugs, and nuclear energy; and she will only appreciate those'bq~ks which satisfy her in-built prejudices. ; Adrian Bridgewater

Managinq Director Hobsons Ltd. Bateman Street Cambridge