UNIT
Values and
6
Challenges in
Health Promotion
Introduction
We have now reached the end of the module and need to stand back and
think broadly about the values within Health Promotion and the challenges
that these imply.
This final unit contains just one session, which serves as a reminder of the
issues and values raised so far, and introduces you to a new concept,
Evidence Based Health Promotion.
Session contents
1
2
3
4
5
6
7
Learning outcomes of this session
Readings
Values revisited
Challenges in practice
Evidence based practice and ethical principles of practice
Module summary
Further reading
Timing of this session
This session contains 4 readings and 4 tasks, one of which is a task relating
to your assignment. It should take you approximately two hours to complete.
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1
LEARNING OUTCOMES OF THIS SESSION
In the course of this session, you will be addressing the session outcomes in the left
column, which relate to the overall Module Outcomes, as indicated in brackets:
Session Outcomes
Discuss the values and ethical
principles of health promotion; (MO 5)
Describe the challenges to address
programmes that comply with the
broad based values of health
promotion; (MO 4, 5)
Reflect on your own practice to
recognise and develop strategies to
tackle the challenges; (MO 3)
Describe and assess the importance of
evidence based practice. (MO 4, 5)
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2
Module Outcomes (MO)
1. Demonstrate critical awareness of the
current debates and dilemmas in
Health Promotion.
2. Demonstrate familiarity with the main
theoretical approaches used in Health
Promotion and awareness of their
strengths and limitations.
3. Demonstrate the ability to plan,
implement and evaluate a Health
Promotion programme.
4. Locate health determinants and
intervention strategies within suitable
models of and approaches to Health
Promotion.
5. Apply Health Promotion and planning
knowledge to a relevant health
promotion issue.
READINGS
The readings for this session are listed below. You will be directed to reading
them in the course of the session.
IUHPE. (2008). Statements: Shaping the future of health promotion: priorities for
action. Health Promotion International, 23 (1): 98-102.
SOPH. (2012). More than a clinical intervention: a health promotion intervention to
address worms in primary school children in Khayelitsha, South Africa.
Thom, A. (2010). Deathly effects of no toilets. Health-e News Service [10.06.2010].
Tannahill, A. (2008). Beyond evidence – to ethics: a decision-making framework for
health promotion, public health and health improvement. Health Promotion
International, 23 (4): 380-390.
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3
VALUES REVISITED
Throughout the module we have emphasised the importance of considering
the context in which people live and the impact it has on their health. This was
considered in most detail in Unit 1. You will remember that we began by
reminding you of the WHO definition of health (WHO: 1948) which extends
beyond the absence of illness to include physical, mental and social
wellbeing. We discussed the social determinants of health and equity, noting
that health is determined by the conditions in which people live and work,
which are shaped by political, social, and economic forces (CSDH 2008), and
that inequities are unjust and unfair. We used the Alma Ata Declaration of
1978, the Ottawa Charter of 1986, and the Commission on Social
Determinants of Health (2008), among other references, to demonstrate the
importance of recognising and working towards social and economic justice
and the right to health.
These aspects may not always be the main focus of your intervention. This
may be because immediate behaviour changes are the most sensible and
realistic approach to achieve your objectives, because they are not part of
your role and so not what is expected of you, or because the task is just too
overwhelming. Working on the details of a specific health education
programme for a particular group of people can seem easier to handle than
addressing the wider determinants of their health, or trying to influence
policymakers in their decision making. You will remember the task based on
the philosophy of Health Promotion by Ewles and Simnett that noted the
different levels and interpretations that exist within health promotion. Another
challenge is that addressing the wider determinants of health extends beyond
the traditional remit of the health sector.
However, it is important to be aware of these broader issues, so that the
interventions you undertake are not placing unrealistic demands on the
people you are working with, and that you are not ‘blaming them’ for their
inability to improve their health. It is also important to explicitly recognise that
any intervention is only part of what is needed, and that it is part of the remit
of Health Promotion to advocate for these wider determinants to be
addressed in collaboration with, or by others.
The first of the following readings is a case study developed by the SOPH in
collaboration with the Medical Research Council of South Africa. This is a long
reading, but try to go through it quickly, leaving out the sections that are not
relevant, and skimming through those which are by now are very familiar to
you. Focus your reading on Section 3, the case context, and then on Section
4, the intervention. The second reading is a health news article which reports
on sanitation in an informal settlement in Cape Town.
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READING
SOPH. (2012). More than a clinical intervention: a health promotion intervention
to address worms in primary school children in Khayelitsha, South Africa.
Thom, A. (2010). Deathly effects of no toilets. Health-e News Service
[10.06.2010].
FEEDBACK
There is no task associated with this reading. However, it is hoped that you
will have looked critically at the strengths of this intervention and the gaps.
What is interesting about this study is that it began with a biomedical
diagnosis of worms, and without the creativity of the health promoters
concerned it would have remained a limited biomedical de-worming initiative.
Instead it has become an innovative multisectoral initiative that includes deworming, but also works in collaboration with the Education Department and
schools to influence the curriculum and the toilet infrastructure in the schools.
Those of you who read the reading in Unit 5 Session 2 by Xu et al, will see the
similarity in approach.
However, it will also be very obvious to you that the living conditions of the
people in the case study are inevitably going to continue to result in poor
health, and that these health problems will be difficult to address without
considering these living conditions.
Now revisit the newspaper article. This is the same one that is listed with
Assignment 2. The article is based on the same township as the worms case
study. It is clearly not possible for the schools intervention to cover all these
aspects. However, the potential, and indeed responsibility of health promoters
includes drawing attention to these wider determinants, and, to focus on worm
infestation, to advocate for improved water and sanitation provision.
4
CHALLENGES IN PRACTICE
We would like you now to reflect on some key challenges in health promotion
practice. After completing the following exercise we will look in a little more
detail at two specific challenges.
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TASK 1
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Write down a list of what you see as the major challenges facing you in
your own practice OR the challenges which face Nomhle.
When you have done this, compare your list with the points we have
raised in the feedback. This exercise provides a useful opportunity for you
to reflect on your own practice; so it would be best for you to first think
about your own challenges before looking at the feedback. The feedback
can only help you consider aspects of your own practice that you had not
previously considered.
FEEDBACK
There are inevitably many challenges you could have noted. We have listed
some which are often raised in discussions with practitioners. If there are any
which are not on your list, decide which it would be useful to add.
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How to deal with demands to use behaviour change approaches when
your own value position is to work collaboratively towards empowerment;
How to persuade others that health promotion needs to work on the social
determinants of health alongside work on individual determinants;
How to get resources to work on what communities themselves define as
their health problems rather than those issues which are defined and
funded by others;
How to build partnerships with others in order to build a settings approach
in schools, workplaces etc;
How to persuade others that effective health promotion requires complex
interventions and not simply the provision of knowledge which people may
already have;
How to engage ‘hard to reach’ groups in the community in health
promotion programmes;
How to persuade colleagues that because we have always done things in
a particular way there can be alternative, and better ways;
How to persuade generous donors that the programmes they want to
support have been shown to be ineffective;
How to be a successful advocate for health;
How to influence policies for health;
How to adopt evidence based practice when it is very difficult to find
evidence which applies to the programmes we are planning;
How to use theory to improve practice;
How to ensure that health promotion practice is ethical;
How to find out what other people are doing in health promotion in my
region or country.
Wise and Jha (2001), in their paper which you read in Unit 1, also reflect on
challenges in health promotion. They are concerned to focus on very broad
issues and offer a vision for the future. If you have the time, look again at this
short reading. They noted these points, amongst others:
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There are shared concerns across the globe. Improving health requires us
to think and act globally, as well as regionally and locally;
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There is a need to refocus on the social determinants of health rather than
the development and implementation of programmes;
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There is a need to influence global and national decisions that affect the
distribution of world’s resources and which impact on health;
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The importance of ongoing attention to the ethics (and values) of our work;
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The need for new evidence to guide policy and practices to achieve equity
and social justice for all and the need for health promotion practitioners to
become better at using evidence to influence policy and practice across
sectors;
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The need for those engaged in health promotion to become effective
advocates for health;
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The need to strengthen the capacity of communities to control and make
decisions that affect their lives and environments;
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The need to ensure that work is based on rigorously derived evidence.
You will notice some similarities between the two lists.
Now read the short paper from IUHPE 2008 paper ‘Shaping the future of
health promotion: priorities for action.’
READING
IUHPE. (2008). Statements: Shaping the future of health promotion: priorities for
action. Health Promotion International 23 (1): 98-102.
Again you will note similar challenges being presented. The priorities listed
include:
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Recommitment to the ideas of the Ottawa Charter;
Comprehensive action on the determinants of inequity and health
The importance of putting healthy public policy into practice;
Since health promotion is delivered through whole systems approaches
involving all sectors the structures and processes in all sectors need
to be strengthened;
Knowledge based practice – based on evidence;
Building a competent health promotion workforce;
Empowering communities.
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5 EVIDENCE BASED PRACTICE & ETHICAL PRINCIPLES OF
PRACTICE
You may have noted references to the importance of adopting evidence
based practice in Health Promotion. The three lists in Section 4 above all
include reference to evidence based practice. McQueen (2001) refers to the
WHO recommendation to:
“… adopt an evidence based approach in health promotion policy and practice, using
the full range of quantitative and qualitative methodologies.” (McQueen, 2001)
In evidence based practice we apply quality research evidence in making
decisions about the planning and carrying out of health promotion
interventions. Different kinds of evidence can be drawn on. When people refer
to adopting evidence based practice they are mostly referring to the use of
published evidence from research and evaluation studies and systematic
reviews of this evidence. However evidence from earlier practitioner
evaluations can also be drawn on. This would be especially relevant for
interventions with a weak or non-existent evidence base.
Evidence of effective health promotion can be reported using a wide range of
indicators including:
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Development of health promoting schools, health centres, workplaces or
other health promoting settings;
Development of policies designed to addressed underlying determinants of
health;
Reduction of health inequities;
Changes in health in terms of mortality or morbidity. e.g. reduction of
children absent from school with diarrhoeal disease following
improvements to water supply in schools and an education programme;
Positive health measures e.g. the percentage of children of 0-5 years
meeting developmental targets;
Health-related behaviours;
Knowledge, beliefs, attitudes;
Empowerment of individuals or communities;
Skills: decision making, advocacy, partnership working, communication;
Measures of intersectoral working.
Depending on their value positions people will differ in the priority they give to
specific indicators. For example, supporters of behaviour change approaches
will want evidence for different indicators than those who prefer an
empowerment approach.
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Why is Evidence Based Practice Important?
TASK 2
Quickly jot down some reasons why practice should be evidence based?
FEEDBACK
The following are a few reasons but you may have several others:
1. Evidence of what has been shown to work in previous evaluations
can help us identify the ways that our current practice can become
more effective. For example, the evidence base on changing eating
behaviours may indicate that effective programmes need to be
holistic, focusing on individual issues such as knowledge, beliefs,
attitudes and skills, as well as changes in the access to appropriate
foods and other enabling factors. Our programmes may have
focused narrowly on individual knowledge and beliefs and ignored
the other important factors.
2. Basing practice on evidence can make better use of scarce
resources. Activities which, on the basis of the evidence base,
have been shown not to work might need to be discontinued. In
some cases, however, the evidence may point to the need for more
complex activities than we have previously used, so additional
resources may actually be needed. For example, evidence from an
evaluation of health promoting schools may reveal that a lack of
success resulted from teachers not being given the time or
appropriate training to develop their understanding of the concept of
the health promoting school and the way to promote its
development. Resources would be needed to provide the time and
necessary training.
3. Making sure that practice is evidence based can make health
promotion more credible with other professionals. You will recall
that we also made this point about credibility when discussing
theory in Unit 4.
Is all evidence of the same quality??
The adoption of evidence based practice originated in medicine and was
taken up later in health promotion. In medicine the quality of evidence has
been rated according to a hierarchy of research designs which generate
quantitative data and prioritise studies carried out using experimental designs
(randomised controlled trials, or RCTs) and systematic reviews of such trials.
This has been widely challenged in health promotion because many of its
interventions are more complex than those of drug and treatment trials and
experimental studies (RCTs) are, in very many cases, not an appropriate or a
feasible form of evaluation. Some people would argue that RCTs are NEVER
appropriate for evaluating health promotion interventions while others would
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argue that they can have a place in evaluating certain types of interventions,
eg those associated with individual behaviour change. This debate is referred
to in the reading for the next task and in the McQueen (2001) paper in the
Further Reading section at the end of this session.
READING
Tannahill, A. (2008) Beyond evidence – to ethics: a decision-making framework for
health promotion, public health and health improvement. Health Promotion
International, 23 (4): 380-390.
TASK 3 – Identify issues relating to Health Promotion in a reading
In the Tannahill paper (pp 381-3), what are the 4 issues relating to Health Promotion
(and health improvement) evidence that he identifies?
FEEDBACK
You should have picked out the following issues:
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The large variety of health promotion actions in terms of subjects and
levels of action for which evidence may be required;
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There is no ‘One size fits all’ method for evaluating health promotion
effectiveness.
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While there is a growing evidence base for some aspects of health
promotion there is a serious lack of evidence in other areas. The evidence
base tends to be more developed for simpler than it is for complex
interventions.
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There will never be effective evidence on everything we would like it for.
In addition evidence alone is not a sufficient base for decision making - we
need to take into account theory and ethical issues
We can also note the continuing domination of the evidence base by research
undertaken in relatively few countries, predominantly from the ‘North’. This
reflects the lack of resources for evaluation and access to publication in many
countries, although the situation is gradually improving. You may find the
McQueen paper in the Further Reading for this session particularly interesting
in relation to this issue.
It is important to emphasise that, in addition to drawing on evidence,
professional skills and knowledge must also be used in making health
promotion practice decisions. As Wiggins and Sansom-Fisher (1998)
stressed:
“ … evidence based Health Promotion therefore comprises a decision making
process whereby quality research evidence is applied in a manner consistent with the
circumstances of a community, their expressed need for interventions, the priorities
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of government and funding authorities and the availability of resources. Neither
quality research evidence nor professional expertise alone is a sufficient basis for
appropriate and effective health promotion”.
(Wiggers & Sanson-Fisher, 1998)
TASK 4: Identify appropriate evidence
What kinds of evidence should Nomhle aim to gather in order to demonstrate the
effectiveness of her programme?
FEEDBACK
Nomhle will probably have developed her own views about what she sees as
the most appropriate evidence to demonstrate the effectiveness of her Health
Promotion activities. For example, she may wish to demonstrate evidence of
community participation in the design and implementation of interventions,
evidence of community satisfaction and evidence of empowerment of
individuals and communities.
She will, however, also be accountable to others who may put pressure on
her to produce evidence of health behaviour change and improvements in
morbidity data evidenced by quantitative data. If this is the case, it will be
necessary to have discussions about these differing demands before finalising
an evaluation strategy.
In practice, most stakeholders may support the idea of generating both
quantitative and qualitative evidence. For example, if Nomhle was supporting
schools in evaluating their sexual health education programme, she might
encourage them to carry out the following:
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A self-completed questionnaire before and after a programme from which
quantitative data would be derived on knowledge, attitudes and reported
behaviours.
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Focus groups generating qualitative in depth evidence on young people’s
views about the sexual health education programme.
These considerations should help you select the most appropriate kinds of
evidence that can demonstrate the effectiveness of Nomhle’s plan, as in the
case study and your assignment question.
As you read through evaluations of Health Promotion programmes, note the
types of evidence that are being collected and the justifications that are
provided for the approach that has been adopted.
While we have focused on the importance of evidence based practice,
Tannahill and others have emphasised other equally important bases for
practice - theory and ethics (values). Return to the Tannahill reading (pp 3847), where he presents a ‘decision-making triangle’ comprising evidence,
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theory and ethical principles. Note also that he offers 10 ethical principles
(p386) which, as you will see, include Health Promotion values discussed
throughout the module and additional principles including ‘Do good’ and ‘Do
not harm’. Tannahill concludes with an ethical imperative for improving health:
‘To make decisions based on the explicit application of ethical principles,
using available evidence and theory appropriately to form judgements.’
Tannahill (2008)
The paper by Raphael (2000) in Further Readings is also worth reading for
more information on evidence based practice in Health Promotion.
In this session we have identified a variety of challenges in planning and
carrying out health promotion. Remember these challenges and the others
that you have identified in your assignments and in your practice. On the
basis of your work for this module and previous experience you will have
some knowledge and skills to draw on in meeting the challenges identified.
More help will come from further study of the module readings but also from
sharing ideas and experience with others working on similar issues. This can
happen through meetings, texting, contributing to newsletters and
conferences. Making links with existing networks (e.g. Health Promoting
Schools, a regional Health Promotion network if you have one) is also a good
way to share experience. Or you may decide to start up a new network. If you
have internet access there are many sources of useful information e.g.
emailing health promoters in your own and other countries, and accessing
websites associated with some Health Promotion textbooks and journal
articles, to which there is a growing free access. Health Promotion is
continuing to develop and all involved can make contributions to this
development. We look forward to reading about your contributions in the
years ahead.
6
MODULE SUMMARY
We have now come to the end of the content part of the module. This
summary should remind you of what you have explored, and hopefully assist
in consolidating your thinking.
In Unit 1, we placed Health Promotion in its broader context, looking at equity,
the right to health and the social and economic determinants of health. This
led to an overview of the development of Health Promotion, showing how it
has shifted from a fairly narrow focus of health education to a broad based
approach, exemplified by the Ottawa Charter. We also noted the shift in
recent years towards investment in health and technocratic approaches.
Unit 2 examined the Ottawa Charter in more detail, starting with the three
strategies of advocate, mediate and enable. We also discussed competencies
in Health Promotion, noting some other relevant competencies, and drawing
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your attention to some of those still to come. The second session looked at
the five action areas, using readings to illustrate them.
Unit 3 discussed the planning process as it applies to Health Promotion. This
was followed by two sessions on Evaluation. Session 2 explored issues in
evaluation for Health Promotion, and Session 3 looked at practical examples
of evaluation.
Unit 4 explored theories in Health Promotion, examining models and
approaches. Included in this unit are some examples of different types of
models, such as models of decision making and models of behaviour change.
Unit 5 shifted the emphasis to collaborative interventions, looking first at the
opportunities and constraints of working collaboratively, at the importance of
working with communities and it revisited advocacy, providing more detail of
this important strategy for Health Promotion. The unit ended with a practical
application of a collaborative approach, using the example of health promoting
settings.
This unit, Unit 6, the final unit of the module, has looked at some of the
challenges in Health Promotion - and has returned to the initial discussion of
the module, to remind you of the values of Health Promotion that include
addressing social determinants, equity, empowerment and social justice.
7
FURTHER READING
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NHS Centre for Reviews and Dissemination. (1999). Effective Health
Care: Getting evidence into practice. York. [Online] Available:
http://www.york.ac.uk/inst/crd/.
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McQueen, D. (2001). Strengthening the Evidence Base for Health
Promotion, Health Promotion International, 16(3): 261-268.
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Raphael, D. (2000). The Question of Evidence in Health Promotion, Health
Promotion International, 15(4): 355-367.
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Tilford, S. (2000). Editorial: Evidence based health promotion. Health
Education Research, (6): 659.660.
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Wiggers, J. & Sanson-Fisher, R. (1998). Ch 8 - Evidence Based Health
Promotion. In S. Scott & R. Weston (Eds). Evaluating Health Promotion.
Cheltenham UK: Nelson Thornes Publishers: 127-145.
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