Last updated: 23 December 1998
... reasonably content people have had their fears aroused and fell
compelled to attempt significant behavioral changes, attempts at which
many (if not most) will fail; some advice is subsequently considered to
have already been harmful; and the public has become confused, and even
skeptical, about public health advice, perhaps especially because we offer
our contradictory advice sequentially (15-16) ... to turn our attention
beyond the individual - to recognize the social and economic determinants
of disease, health and "wellness" - is complex and threatening
(19) ... the individual-responsibility approach has helped to establish
"health" as the New Morality by which character and moral worth
are judged. "Being ill" is redefined as "being guilty".
The obese are stigmatized as "letting themselves go". Smokers
"have no will power". Nonaerobics are "lazy" (19).
The evidence here, as elsewhere, suggests that education is certainly
relevant, but more because better education is associated with general
differences in patterns of life than because discrete parts of a lifestyle
can be changed. Health-change policies which focus entirely on the individual
may be ineffective not only because exposure to health risks is largely
involuntary, but also, as this study has shown, because of unwarranted
assumptions about the extent to which behaviour can, in these circumstances,
be effective in improving health.
key areas for action:
Health promotion is ... the social action dimension of health development.
The truth is that both medicine and health promotion have a scientific
basis, and both deal with prescriptions for improving the quality of life.
The differences are between perspectives: the individual and the societal;
the negative and the positive; the curative and the preventive; the reductivist
and the holistic.
... we must have a good grasp of a philosophy of health promotion, its
principles and justification, or we shall be lost in a morass of empirical
detail and tips for day-to-day business.
Health promotion comprises efforts to enhance positive health and prevent
ill-health, through the overlapping spheres of health education, prevention,
and health protection.
But solving problems of disease is not the same thing as creating health
and happiness. (...) Health and happiness are the expression of the manner
in which the individual responds and adapts to the challenges that he meets
in everyday life.
But too often the goal of the planners is a universal gray state of
health corresponding to absence of disease rather than to a positive attribute
conducive to joyful and creative living. This kind of health will not rule
out and may even generate another form of ill, the boredom which is the
penalty of a formula of life where nothing is left unforeseen.
Similarly, if health promotion results in a group of professionals deciding
what is best, and setting about to program the population to behave in
that way, the costs of such activity are likely to outweigh the benefits
in the long run.
Health promotion, then, is the active process of disease prevention
encompassing educational components, including individual and group change
and social influence techniques which, together with environmental, legislative
and organisational interventions, make up a range of strategies for better
- The professional health promotion practicioner, by necessity needs
to be a 'specialist in generalisation'.
Market forces have little effect on programs for those who are in real
need, but do not have the ability to pay.
The traditional focus of health promotion campaigns on individual risk
should, by now, be seen as only a small part of health promotion strategy.
Promotion of health generally by improving the standard of living. From
the health point of view we are in this connexion first and foremost interested
in the three fundamental environmental factors: housing (including family
life), nutrition, and working conditions (including human relations as
well as material conditions).
The most sophisticated and effective health care in the world cannot
produce results as good as simply remaining healthy in the first place.
Our ancestors tithed in hope of life after death; we hope for more and
better life before death.
Why do we make a distinction between socially unacceptable and socially
acceptable lifestyles, even though both may lead to disease and dysfunction?
We excoriate the smoker but congratulate the skier. Yet both skiing and
smoking may lead to injury, may be costly, and are clearly risky. We have
created a new medical speciality to take care of sports injuries, an acknowledgment
of the hazardous sequelae. And though there are no doubt benefits to exercise
and sports, the literature on the complications of some activities is such
that were they drugs, they would probably have been banned by the Food
and Drug Administration years ago. (...)
It has always been easier to recognize personal weaknesses in socially
marginal groups than in the "better" classes. There is a great
deal of moral posturing in the health promotion debate.
Health promotion, even when it may be state sponsored and seemingly
coercive, becomes more acceptable when medicine cannot provide cures for
the dominant illnesses that plague society. This point is well illustrated
in the current debate over life-style modification policies.
Disease prevention and health promotion involve decisions affecting
not only a person's pride and pocketbook but also his or her body, soul,
I would say that the first job of professional people in health promotion
is to find out what is the minimum you can do. What is the minimum undertaking
for the health professions, for government, to facilitate the process of
people getting indeed what they want. Find what the barriers to achievement
are, whether it is in terms of access to social relations or to information
appropriate to good quality decision making. So our task, I think, is a
minimal task, one which says that we have a very humble but very important
role, that is to find what it is that is standing between the public's
interest in health and their achieving it and what we can do to ensure
that they get there with the least amount of our effort (or control).
Health is the new disease, and we can apply to the concept of health
precisely the language and style and strategies of operation that we apply
to the world of disease. Health is even better than disease (in maintaining
the disease care establishment) because everybody wants it. Everybody wants
health and we have for the first time the only disease that everybody wants.
We will now be able to manage this disease programme without much effort
and motivation to get people to undertake advice and counsel and care and
technology or whatever is necessary to achieve (or control) it. And, of
course, we the experts in public health have a technology and the knowledge
to undertake to organize curricula, programmes, institutional care and
the like to improve the health status of anybody who is serious about catching
this particular disease and holding on to it.
Health promotion represents at the very simplest level, whether one
adopts a structuralist or individualistic approach to health, a strategy
for promoting, in some positive way, the health of whole populations.
The 'let's'all go jogging, stop smoking and eat brown bread' type of
health promotion campaigns have failed to reduce the health inequalities
experienced by people subjected to modern-day poverty. Individualising
the problem and the solution only damages the moral and spiritual health
of the nation.
In a democratic society that seeks at least internal equanimity, if
not humanness and social justice, the responsibility of government is to
establish environments that make possible an attainable level of health
for the total population. This responsibility includes the assurance of
environmental circumstances that do not impose more risks to health for
some segments of the population than for others, for such inequality of
risk would doom some groups of people - regardless of their choice - to
a reduction in opportunities to develop their capacities.
If health is inextricable from its environmental origins, then health
policy cannot be separated from other major areas of policy (...) The healthy
responses of individuals - their capacity to respond to circumstances in
ways that enables them to pursue their chosen round of life without personal
restrictions - depend upon the choices of policy-makers in government and
corporations (...) In this view, the most salient strategies are those
that affect the larger dimensions of environment - the biophysical and
socioeconomic conditions of workplaces, homes, and communities (...) Supportive
strategies, such as educational information and personal services, are
effective only when they help people do what is possible within their environments.
These supportive efforts are thus effective within the context of policies
that create enabling environments. By themselves, they are dubious and
often band-aid efforts.
An ecological framework for the development of health policy is, in
essence, an integrated approach. Focused on prevention, its component policies
and strategic thrust aim toward developing opportunities for health-making
choices by organizations and individuals. Its policy components would be
designed to make the creation and maintenance of healthful environments
and personal habits the easiest - the 'cheapest' and most numerous - choices
for selection by governmental units and corporations, producers and consumers,
among all the options available to them. Policies would emphasize the aspects
of environments and ways of living which have largest potential for promoting
Environmental changes may be the simplest and possibly the cheapest
means to promote and support an individual's behavioral change. Moreover,
consideration of organizational-level factors such as work design or climate
may produce greater health benefits than focus on the individual.
Health promotion is the science and art of helping people change their
lifestyle to move toward a state of optimal health. Optimal health is defined
as a balance of physical, emotional, social, spiritual and intellectual
health. Lifestyle change can be facilitated through a combination of efforts
to enhance awareness, change behavior, and create environments that support
good health practices. Of the three, supportive environments will probably
have the greatest impact in producing lasting changes.
In both a policy and research framework, the usual goal is to obtain
hard measures or variables; objectivity is the accepted standard and subjectivity,
suspect. In moving away from the old models, however, people must face
the importance of subjective aspects of health. Most studies examining
the relationships between input (such as living conditions or social support)
and health finally arrive at the conclusion that how people appraise or
perceive input is more important than the objective nature of the input.
With a variable such as coping ability, perceived rather than actual ability
is related to health ... On the output side, the whole area of health policy
and research has been strongly led by the desire to show impact in terms
of hard indicators: typically disease, death or other biomedical measures
... The role of subjective measures will be of increasing importance if
justice is to be done to the broad new multidimensional approach to health
heralded by the Ottawa Charter.
Individual life style changes are unlikely to occur, at more than a
minimum level, without the economic and structural support which is necessary
as a foundation for such changes.
The emphasis on 'healthy' individual lifestyle, on individual responsibility
for health, and on the assumption that individual behaviour can - if backed
up by educational measures - resist the powerful social forces acting upon
it, can be seen as an attempt to legitimize cost-containment arrangements
and, thus, divert attention from social reforms.
Policies for the promotion of health need to integrate the issue of
health into a wider social, economic, and political context. This complexity
cannot be handled within the narrow framework which characterizes most
of current public policy-making.
When health problems are seen to inhere in individuals, rather than
being endemic to social structure and circumstances, attention is directed
towards short-term solutions only and the conditions which are largely
responsible for the problems remain constant.
To acknowledge the possibility of choice within discourses other than
health as equally valid would undermine health promotion's claim to scientific
rationality. If health promotion were truly to accept all choices as equally
valid, the role of health (italic!) promotion would be reduced to promoting
access to and decision making about services, and the dominance of the
rational, medico-scientific paradigm would be challenged. It would be possible
for other social formations to arise, for competing social norms and values
to move into ascendance.
Professionalism is about power and prestige, whereas community education
and community development require a willingness on the part of professionals
to share their power, knowledge and skills with lay people, even to work
to make themselves redundant. How do we prepare established health and
social services for the fact that successful community development and
community action on health issues tends to create initial friction between
community leaders and established providers of services?
... the principle of beneficence (to do good rather than harm) has been
taken to imply several kinds of moral duty - the duty to protect the vulnerable,
the duty of advocacy and a general duty to care. The principle of justice
relates ... more fundamentally to distributive justice or the requirements
of universal fairness, i.e. non-discrimination against and equal opportunity
for individuals, and equality of outcome for groups. Respect for others
has been interpreted to mean not only respect for the life, dignity and
bodily integrity of the individual, but als respect for the autonomy and
rights of the individual, e.g. the right to know, the right to privacy
and the right to adequate care and treatment.
Health promotion strives to contribute to health development through
three principle strategies:
Copyright © by Eberhard Wenzel, 1997-2001