Health education and health promotion FROM PRIORITIES TO PROGRAMMES
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Health education
and health promotion
FROM PRIORITIES
TO PROGRAMMES - extracted text
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Health education
and health promotion
FROM PRIORITIES
TO PROGRAMMES
The experience of the
Health Education Board for Scotland
Health education
and health promotion
FROM PRIORITIES
TO PROGRAMMES
The experience of the
Health Education Board for Scotland
Health education
and health promotion
FROM PRIORITIES
TO PROGRAMMES
The experience of the
Health Education Board for Scotland
Andrew Tannahill
Health Education Board
for Scotland
General Manager
Health Education Board for Scotland
THE AUTHOR
Andrew Tannahill mb, chB, MSc, ffphm, mhsm became the
first General Manager of the Health Education Board for Scotland in
June 1991. He graduated in Medicine from the University of
Glasgow in 1977, and in Community Medicine from the University
of Edinburgh in 1982. He has held a range of service and academic
public health appointments in Scotland and England. He is currently
an Honorary Senior Lecturer in the Department of Epidemiology &
Public Health of the University of Dundee and an Honorary Fellow
in the Department of Public Health Sciences of the University of
Edinburgh.
First published in the UK by Health Education Board for Scodand
on behalf of World Health Organization Regional Office for Europe
© Health Education Board for Scodand 1994
Woodbum House, Canaan Lane, Edinburgh EH 10 4SG, UK.
Target 13 - Healthy Public Policy
By the year 2000, all Member States should have developed, and be implementing,
intersectoral policies for the promotion of healthy lifestyles, with systems ensuring public
paraciparion in policy-making and implementation.
Keywords:
* Health education
• Health promotion
• International cooperation
• United Kingdom
• Europe
Reference number EUR/ICP/HSC/646/1
All rights in this document are reserved by the Health Education Board for Scodand and the
WHO Regional Office for Europe. The document may nevertheless be freely reviewed-,
abstracted, reproduced or translated, but not for sale or in conjunction with commercial
purposes. Any view expressed by the author is solely the responsibility of the author. The
WHO Regional Office for Europe would appreciate receiving three copies of any translation.
FOREWORD
Most European countries are currently introducing reforms in the
field of health policy. The great majority of these reforms, however,
are limited to issues of the financing and provision of medical and
hospital services. Only a very few reformers examine the type of
policies needed to create health. It is vital to ensure that health
promotion plays an increasingly prominent role in the reforms.
The concept and principles of health promotion as defined in
the Ottawa Charter for Health Promotion continue to do much to
carry the current debate on reforms forward. WHO/EURO in its
role of providing leadership in health development has taken several
initiatives, to provide information and expertise, with the aim of
meeting the challenges and opportunities for health promotion in
today’s fast changingjEurope.
A new ‘health promotion country series’ of publications is the
latest of these initiatives. It has been launched with the aim of
increasing opportunities for exchanging information and sharing
experiences in health promotion policy formulation and delivery
across national boundaries. The theme chosen for this first issue is in
response to requests by a number of WHO Member States and
collaborating centres for examples of how health promotion is
conceived and delivered by focusing on schools, workplaces and
other key settings where people spend their everyday lives.
The Scottish experience, to which this first number of the new
series is devoted, offers a clear example of how to progress topics
(such as smoking, alcohol misuse, coronary heart disease and cancer)
in settings. Dr Andrew Tannahill’s analysis demonstrates why certain
decisions have been taken by the Scottish national health education
organisation, and the consequences they are likely to have. The paper
was originally presented at the 4th meeting of WHO health
promotion counterparts and collaborating centres held in Tampere,
Finland in November 1993. Dr Tannahill’s contribution proved to be
an invaluable catalyst for discussion and exchanges among the member
states represented at the meeting. One outcome of the debate at the
meeting is that the health promotion unit of WHO/EURO decided
to produce the country series of pubheations.
It is our hope that the series will provide special insights into
opportunities and problems faced by countries, and inspiration
towards rising to meet them.
Erio Ziglio PhD
Regional Adviserfor Health Promotion
Department of Lifestyles and Health
World Health Organization
Regional Office for Europe
vi
NUMBER 1
9
The Health Education Board for Scotland (HEBS) was established on
1 April 1991, replacing the Scottish Health Education Group
(SHEG) as the national agency for health education in Scotland. The
creation of the new organisation followed a fundamental review of
health education commissioned by The Scottish Office, and arose
from the publication of Health Education in Scotland: a National Policy
Statement1. The latter stressed the importance of health education,
within the broader context of health promotion; presented priorities,
objectives and targets for achievement; and outlined the roles and
responsibilities of a number of relevant agencies and groups. The
principles set out in that document were further developed in a
subsequent national policy statement, Scotland’s Health: a Challenge to
Us All2.
The national policy statements identified the following as first
order priorities towards which health education efforts in Scotland
would be principally directed:
• coronary heart disease
• smoking
•alcohol misuse
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HEALTH PROMOTION COUNTRY SERIES
INTRODUCTION
• drug misuse
• cancer
•H1V/AIDS
•accidents
•dental and oral health.
In addressing these priorities, a combination of specific
measures and a more general ‘positive healthy lifestyle’ approach was
called for. The importance of diet and exercise in the promotion of
health was highlighted.
2
NUMBER 1
PRIORITIES
TO PROGRAMMES:
As is usually the case, the top priorities set out in the national
policy statements are health-related topics-—specific risk factors and
categories of health/ill-health. An important early task for HJEBS was
to decide how these priorities could be best translated into national
programmes of health education action.
The traditional answer to this question is to devise a programme
for each topic. Thus it is commonplace for health education/promotion
agencies to have a coronary heart disease (CHD) programme, a
smoking programme, a cancer programme, a dental/oral health
programme, an alcohol programme, and so on. Each of these
programmes has to try to reach the public through mass media and
through a range of settings and sectors—schools, health care settings,
the workplace, various other community settings and the voluntary
sector (Figure 1). In other words, they each must attempt to operate
in the same range of health education ‘arenas’. This topic-based
approach is seriously flawed.
The first, and most fundamental, problem with the approach
arises from the fact that there are extensive overlaps between topics.
Links between the Scottish first order priorities are shown in
3
HEALTH PROMOTION COUNTRY SERIES
the traditional approach
Fig. 1. Priorities to programmes: the traditional approach
PRIORITY TOPICS/
PROGRAMMES
ARENAS
Figure 2 (the most direct and significant being represented by the
thicker lines.)- The topic of alcohol misuse provides a good example
of the overlaps. Misuse of alcohol is an established risk factor for a
number of cancers; it is commonly implicated in the causation of
accidents; through depression of inhibitions and impairment of
condom commitment and competence, it may affect sexual behaviour
in such a way as to increase the risk of transmission of HIV (as well as
the risk of other sexually transmitted infections and of unwanted
pregnancy); it can contribute to a number of dental/oral health
problems, including oral cancer and traumatic damage (through
accidents and assaults); as a behaviour it has links with the use of
tobacco and other drugs; and it is a risk factor for hypertension,
which is in turn associated with CHD.
The existence of these and many other overlaps means that
health education programmes centred on individual disease and risk
factor topics lend themselves to duplication of effort, without
adequate coordination of the content and timing of activities. This is
at best wasteful, at worst damaging. Separate initiatives on specific
4
topics often, in effect, compete with one another, and there is a danger
of inconsistency3 of ‘messages’, which may provide the public and
professionals alike with just the excuse they need to take no action.
Coordination of effort—of content and timing—across topics is central
to efficiency and effectiveness in health education. This requires an
approach different from the topic-based approach. It quite simply
makes no sense to deal with topics in absolute or relative isolation
from one another.
Added to the problems of undesirable duplication of activities
is the fact that it is unrealistic to expect a manager or team concerned
with a given topic to exploit the potential in all of the various arenas.
Moreover, the principal qualifies necessary to be an expert in a topic
differ from those needed to deliver health education programmes.
The acquisition and maintenance of topic-based expertise calls for
the investigative and critical appraisal skills of the researcher, while
programme delivery requires skills in education, communication,
networking and project management. This distinction has long been
neglected.
5
Also, it is necessary to consider the perspectives of those who
work in the various key settings and sectors, who can provide (or
deny) access to these arenas, and whose active participation is essential
for success. Such people include education authority representatives
and officials, and headteachers of schools; hospital and primary care
managers, doctors and nurses; heads of industrial and commercial
companies, workplace managers and trade union officials; and workers
in voluntary organisations. To them topic-based programmes result in
a feeling of being bombarded (from above—the classic ‘top-down’
situation) by a disjointed set of demands from various people, pressing
the importance of their own topics with little or no regard to initiatives
on other topics. In such a situation, the headteacher of a school, for
example, may feel unable to incorporate a whole series of
programmes into an already crowded curriculum, and may reasonably
also feel unhappy at not having been involved at development stages.
Moreover, he or she is likely to be concerned at the fact that the
topic-based approach is disjointed and overlooks the need to develop
an infrastructure and methodologies specifically geared to the school
setting, relevant to the full range of preventive topics as well as to the
promotion of lifeskills, fitness and well-being, and providing appropriate
inputs at the various stages of the school career. The undesirability of
trying to incorporate topic-based programmes into the curricula and
extracurricular activities of schools is widely recognised, and comprehensive,
coordinated schools health education programmes are established, or
being established, in many countries. The same reasoning is equally
applicable to all other settings and sectors.
6
NUMBER 1
PRIORITIES
TO PROGRAMMES:
The foregoing considerations led HEBS to the intention to discard
topic-based programmes in favour of coordinated programmes centred
on key arenas for health education (Figure 3). Thus, a coordinated
programme of health education for the general public, with extensive
use of high-profile mass media initiatives, would be combined with a
set of programmes relating to important settings and sectors. A further
programme would be required to enable HEBS to capitalise on
emergent opportunities, respond to urgent needs and take part in
special events on particular topics.
The following programme headings were proposed:
• general public
. community
• health service
• schools
• voluntary sector
• workplace
• special projects.
The details of, and rationale for, the way ahead were presented
in the HEBS Strategic Statement4, a consultation document distributed
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HEALTH PROMOTION COUNTRY SERIES
the HEBS approach
Fig. 3. Priorities to programmes: the HEBS approach
PRIORITY TOPICS
PROGRAMMES/
ARENAS
etc
widely within Scotland in March 1992. The Board’s proposals were
widely welcomed and became the central plank of the Boards strategy,
as presented in the Strategic Platt 1992 to 1997’. The programmes,
each headed by a programme manager in the Programmes Division,
are now at various stages of development.
The programmes together facilitate:
•comprehensive coverage of the community, reaching people
wherever they live, work, spend leisure time or seek help
•linkages between national-level health education and
more local efforts
• the drawing together of topics in a systematic and
coordinated way
•appropriate phasing of action on the various topics,
avoiding ‘overloading’ of the public, health promoting
agencies and professionals at any point in time
• the mounting of mutually reinforcing activities in
multiple arenas, as appropriate
• the striking of an appropriate balance in setting/sector-based
8
Strong topic-based inputs are provided by specialist officers in
the Development and Evaluation Division of HEBS, each with
responsibility for a cluster of topics. In relation to their topics, these
officers play key roles in needs assessment, the shaping of programme
content, and pre- and post-implementation evaluation of initiatives.
1
NUMBER
HEALTH PRO M O TIO N COUNTRY SERIES
programmes between activities which support and
capitalise on general public programme initiatives and
work which arises more directly from specific needs
and opportunities in particular settings/sectors
•the achievement of a judicious mix of preventive health
education and positive health education, the latter placing
an emphasis on enhancing positive health attributes6,
such as lifeskills, and on promoting physical, mental
and social well-being and fitness
•the development of infrastructures and sound
methodologies tailored to the needs and circumstances
of each of the arenas, and of relevance across the spectrum
of health education topics
• appropriate participation by a wide range of individuals
and agencies in devising and implementing programmes
and projects
• the design and implementation of education and training
initiatives for existing and potential ‘health promoters’ in the
various arenas
• responsiveness to the needs of the community.
THE
BROADER CONTEXT
OF HEALTH PROMOTION
An additional advantage of the strong emphasis on settings and sectors
is the ease with which health education efforts may be placed within
the broader context of health promotion, which is commonly viewed
as embracing preventive services (such as immunisation and screening)
and health protection policies, as well as health education7-8. Thus,
for example, the HEBS workplace programme, once fully established,
will aim to develop the full potential of the workplace as a setting for
health promotion, encouraging the provision of appropriate preventive
services and the devising of policies designed to create environments
conducive to good health. Similarly, the schools programme is set
within the concept of the health promoting school9-10.
10
NUMBER 1
HEBS has had to move as quickly as possible towards the new
approach while maintaining, and indeed expanding, outputs on
priority topics.
In the transition phase, activities continued to be centred
mainly on topics, but attention was paid to the needs and opportunities
Fig. 4. Implementation of the HEBS approach: transitional stage
Topics
Programmes
Smoking
Alcohol
misuse
Drug
misuse
etc
General
public
Schools
Health
service
etc
■iA-
L11
HEALTH PROMOTION COUNTRY SERIES
IMPLEMENTATION
for action on particular topics in each of the planned programme arenas
(Figure 4). The resulting topic-based initiatives in the arenas provided
foundations on which to build the new programmes.
As the programme managers have taken up post during the
past year, the dynamic has changed from ‘down the columns’
of the programmes/topics matrix (Figure 4) to ‘across the rows’
(Figure 5). That is to say, the programme managers have begun to
develop networks, infrastructures and methodologies within their
arenas, while incorporating appropriate activities on specific topics
with the support of the newly-appointed specialist development
and evaluation officers.
The transition has been remarkably smooth, and the benefits of
the new way of working are already being seen within HEBS and
beyond. The approach is commended to other agencies.
Fig. 5. Implementation of the HEBS approach: filly established
Topics
Programmes
General
public
Schools
Health
service
etc
12
Smoking
Alcohol
misuse
Drug
misuse
etc
NUMBER 1
REFERENCES
The Scottish Office Home and Health Department.
Health education in Scotland: a national policy statement. Edinburgh:
The Scottish Office, 1991.
2 The Scottish Office. Scotland’s health: a challenge to ns all.
Edinburgh: HMSO, 1992.
3 Tannahill A. Health education and health promotion: planning for
the 1990s. Health Education Journal 1990; 49: 194-198.
4 Health Education Board for Scotland. Strategic statement: a
consultation document. Edinburgh: Health Education Board for
Scotland, 1992.
5 Health Education Board for Scotland. Strategic plan 1992 to 1997.
Edinburgh: Health Education Board for Scotland, 1993.
6 Tannahill A. Health promotion and public health: a model in
action. Community Medicine 1988; 10: 48-51.
7 Tannahill A. What is health promotion? Health Education Journal
1985; 44: 167-168.
8 Downie K S, Fyfe C, Tannahill A. Health promotion: models and
values. Oxford: Oxford University Press, 1990 (pp 57-60).
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1
Scottish Health Education Group, Scottish Consultative Council
on the Curriculum. Promoting good health: proposals for action in
schools. Edinburgh: Scottish Health Education Group, 1990.
10 World Health Organization, Council of Europe, Commission of
the European Communities. The European network of health
promoting schools. Copenhagen: World Health Organization,
Council of Europe, Commission of the European Communities,
1993.
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