HEALTH PROMOTION

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Title: HEALTH PROMOTION
extracted text: RF_COM_H_95_SUDHA

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Social Psychology and Health Education

Ger jo Kok PhD1/ Herman Schaalma PhD1, Hein de Vries PhD1,
Guy Parcel PhD1,2' & Theo Paulussen PhD3

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1

Department of Health Education, University of Limburg, Maastricht, The
Netherlands

2

University of Texas Houston Health Science Center, Center for health
Promotion Research & Development, School of Public Health, TX

3

Dutch Center for Health Promotion & Health Education, Utrecht, The

Netherlands

Corresponding author: Gerjo Kok
Department of Health Education, University of Maastricht
P.O. Box 616, 6200 MD Maastricht, The Netherlands

1

Abstract

This chapter addresses the contribution of social psychology to the field

of health education. After a short introduction to health education, the
role of social psychology is addressed. This role is referred to as

problem-driven applied social psychology. Subsequently, the chapter
describes general and specific theories that can be applied for the
analysis of psychosocial determinants of health related behaviours. the

development of theory-based and data-based interventions programs. and
theory-based and data-based implementation planning. For each of these

phases the chapter presents a research protocol illustrated by studies in

the areas of smoking prevention and AIDS prevention.

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1

Planned Health Education and Health Promotion: Concepts

Health promotion
Planned health education

The role of social psychology
2

Problem-Driven Applied Social Psychology

Problem-driven versus theory-driven applied social psychology

Disadvantages of a mono-theoretical perspective: Risk perception

Disadvantages of a mono-theoretical perspective: Causal Attribution
Multiple theories may be useful

3

Psychosocial Behavioural Determinants
Theories of behavioural determinants

A protocol for measuring and analyzing behavioural determinants

Measuring and analyzing the determinants of smoking
Measuring and analyzing the determinants of (un)safe sex

4

Health Education Programs
Theories of behaviour change through communication

A protocol for developing theory-based and data-based health education
programs

Developing programs for smoking prevention
Developing programs for aids prevention
5

Implementation of Health Education
Theories concerning implementation

A protocol for theory-based implementation planning

Implementation of smoking prevention programs

Implementation of AIDS prevention programs
6

Conclusions

3

Social Psychology and Health Education

1

Planned Health Education and Health Promotion: Concepts

Health promotion

Health education is a planned activity stimulating learning through

communication to promote healthy behaviour (Green & Kreuter, 1991). The

concept of health education needs to be distinguished from the concept of

health promotion. Health promotion refers to 'any planned combination of
educational, political, regulatory, and organizational supports for actions

and conditions of living conducive to the health of individuals. groups, or
communities'

(Green & Kreuter, 1991, p. 432). In addition to the promotion

of health, the goals of health promotion include three types of prevention:

1) primary prevention; 2) early detection and treatment; and 3) patient
care and support. Health education refers to 'any planned combination of
learning experiences designed to predispose, enable, and reinforce

voluntary behaviour conducive to health in individuals. groups, or
communities'

(Green & Kreuter, 1991, p. 432). As such. health education is

one of the means of achieving the goals of health promotion. Other health

promotion instruments are: resources, pricing and regulation. Whereas
health education is based on voluntary change, regulation is based on

forced compliance. This implies that regulation may only be effective in
combination with control and sanctions. Health promotion is the combination

of goals and means, often through empowerment of communities. Generally,
health promotion programs directed at various levels and using various

means will be most effective (De Leeuw, 1989; Milio, 1988; Simons-Morton et
al., 1988).

An example: Drunken driving

With regard to drunken driving most countries have laws against driving
4

under the influence of alcohol (regulation). In most countries control
activities are undertaken to endorse these laws, although countries differ
in their commitment to these activities . When resources are considered, one
may think of cheap taxis for young people, and of public transportation.

especially in the weekends and during the night. And, last but not least.
there may be education about the rules and possible sanctions, about

resources, and about drunken driving itself (that is, about the
consequences of drunken driving, and about ways to prevent getting into

that situation). The combination of control, resources and education is
usually most effective; control. resources, or education on their own would

probably not have much effect.

Planned health education

Health education is a planned activity. The best known and most frequently

used planning model in health education and health promotion is Green's
PRECEDE/PROCEED model (Green & Kreuter, 1991). In short. this model states

that health promotion should start with a social diagnosis. also called
social needs assessment or social reconnaissance. Social diagnosis is
defined as the process of determining people's perceptions of their own

needs or quality of life, and their aspirations for the common good (Green

& Kreuter, 1991, p. 45) . The second phase in the model is the
epidemiological diagnosis which is conducted to determine two things: 1)

which health problems are important ' objactively' ; and 2) which behavioural
and environmental factors contribute to the occurrence of those health

problems (Green & Kreuter, 1991, p. 90) . The third phase of the model. the
behavioural and environmental diagnosis, includes the systematic analysis
of the behavioural, social and environmental factors that are linked to the
goals or problems that were identified in the epidemiological or social

diagnosis. In this phase the determinants of health are analyzed in terms
of behaviour, lifestyle, and environment. The fourth phase, the educational
and organizational diagnosis, examines the determinants of the behavioural

and environmental conditions that are linked to health status or quality-

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of-life concerns. It also identifies the factors that must be changed to
initiate and sustain the process of behavioural and environmental change.
Three categories of factors can be distinguished: 1) predisposing factors,

referring to behavioural antecedents that provide a rationale or motivation
for behaviour; 2) enabling factors, referring to behavioural antecedents

that enable the realization of a motivation; and 3) reinforcing factors.

referring to factors subsequent to a behaviour that enhance its persistence
or repetition. The model's fifth phase, the administrative and policy

diagnosis, addresses the analysis of the possible usefulness of health
education and other potential interventions (resources, regulations). This

phase also refers to the political, regulatory, and organisatory factors
that may facilitate or hinder the development and widespread implementation
of a health promotion program. Subsequent phases of the model refer to the
evaluation of the process, impact, and outcome of the health promotion

intervention, resulting in feedback and improvement of the programs.

A planning example

In most Western countries the quality of life in general is high {social
diagnosis). People consider health as one of the most important aspects of

their quality of life. The most important health problems that are
demonstrated by mortality analysis are cardiovascular disease and cancer

{epidemiological diagnosis). Environmental factors influencing

cardiovascular disease and cancer are industrialization and an unhealthy
working environment. Behavioural factors influencing cardiovascular disease

and cancer are smoking and an unhealthy diet {behavioural and environmental

diagnosis). When smoking, and the prevention of the onset of smoking in

particular, is considered as the behaviour that we want to influence.
research has shown that young people start smoking because of social

pressure, mostly from peers, family or mass media, and not because they

like it and have little knowledge of the dangers {educational and

organizational diagnosis). Young people often do not know how to resist
social pressure (predisposing factors), and belonging to a peer group is

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♦

usually very important for them (reinforcing factors). In addition,

cigarettes are easy to get and sanctions against smoking are weak (enabling
factors). What can be done to change the onset of smoking? When health

education is considered, young people's self-efficacy in resisting social

pressure may be enhanced. Several techniques may help young people to learn
how to resist pressures to smoking, for instance positive role modelling

(see Evans et al., 1988). When resources and regulation are considered.

anti-smoking policies may be developed, for instance in schools, or through
community action against vendors selling cigarettes to young people under

legal age (administrative and policy diagnosis) . The implementation of such
a health promotion program can be organized in co-operation with schools.
parents and young people. Finally, the effectiveness of the program has to

be assessed. Was the program implemented as planned, and was the supposed

self-efficacy improvement actually established (process evaluation)2 Did
the program lead to a reduction in the number of young people who start
smoking (impact evaluation)2 It may be clear that an improvement in terms

of health outcomes, reduction of cardiovascular diseases and cancer, and
quality of life, cannot be expected for several years (outcome evaluation).

The planning process of health education programs is a cumulative and
iterative process. On the one hand. answers to earlier planning questions

are needed for decisions in later phases. On the other hand. the process is

flexible instead of rigid, and going back and forth through the model may

be necessary. During the planning process existing knowledge that is
systematized in theories, and that is available as empirical data are used.

The role of social psychology

Health education and health promotion are multi-disciplinary activities
that draw from various basic sciences. The contribution of social
psychology to health education is relevant if not essential for the
behavioural diagnosis, for the analysis of possible intervention programs.
and for program implementation. In these phases the main focus of attention

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4

♦

is the behaviour of individuals and groups in their social environment.

This chapter primarily describes the application of social psychological

theories within the area of health education for primary prevention. Social

psychology also contributes to other health promotion objectives: early
detection and patient education and support, for instance with theories

concerning decision making (Janis & Mann, 1977), coping (Lazarus, 1991),

bereavement (Stroebe et al., 1993), social comparison (Affleck & Tennen,
1991; Taylor et al., 1986), and stigmatization (Jones et al.. 1984; Katz,
1981). And social psychology also contributes to other types of
interventions: resources, pricing, and regulations, for instance with

theories concerning consumer behaviour (Van Raaij et al., 1988), risk
homeostasis (Wilde, 1986), and social dilemmas (Messick & Brewer, 1983) .

The main concern of the present chapter is, however, promoting healthy

behaviour through health education for primary prevention.

2

Problem-driven applied social psychology

Problem-driven versus theory-driven applied social psychology

Within the field of applied social psychology basically two activities can
be distinguished: theory-driven and problem-driven applied social

psychology. Theory-driven applied social psychology refers to testing a

theory in an applied setting, merely to get insight into the validity of
the theory. Although theories are tested in practice, the primary focus is
on theory testing and the criteria for success are formulated in terms of

theory development. Contributions to solving practical problems are a nice

but unnecessary side effect. Problem-driven applied social psychology
refers to scientific activities that focus at changing or reducing a
practical problem by using a transtheoretical (social) psychological

approach. Although theories are used, the primary focus is on problem
solving and the criteria for success are formulated in terms of problem

reduction. Contributions to theory development are a useful but unnecessary
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side effect.

It may be clear that problem-driven applied social psychology is
essentially different from theory-driven applied social psychology.

Problem-driven applied social psychologists have to start with a thorough
analysis of the practical problem in question, and they have to consider

multiple theoretical perspectives to find answers to this problem. In
theory-driven applied social psychology practical problems are usually

considered from a mono-theoretical perspective; practical settings are
merely used for theory testing. Theory-driven applied social psychology is

useful in linking important theoretical developments to human behaviour

outside the laboratory. Problem-driven applied social psychology is an
important activity because it is the ultimate test for the usefulness of
social psychology as a discipline and a profession.

Disadvantages of a mono-theoretical perspective: Risk Perception

The Dutch Foundation for Traffic and Safety has a long history of educating

parents of young children to promote the consistent use of child restraint

devices in cars to protect their children against the potentially harmful
consequences of an accident. However, there were still a high number of car
accidents in which children were the victim. The Foundation decided to find
out why their educational programs did not work and how these programs
could be improved.

Let us assume that this problem is considered by a theory-driven social
psychological researcher whose primary interest is in theories of risk

perception. One reason that can be derived from theories in the area of
risk perception and risk behaviour has to do with unrealistic optimism:
people systematically underestimate their own risk compared to others (Van

der Pligt et al., 1993; Weinstein, 1988). In this case, this theory would
predict that parents are convinced: a) that they have a lower chance of
being involved in an accident than other drivers. and b) that they are more

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able to control the possible consequences of an accident than others, for

instance, by holding their child very tightly. Informal interviews with

parents supported these theoretical predictions. Explanations of the
process of unrealistic optimism suggest that parents should be taught that
other parents also take measures to protect their children, and that car

accidents are partly uncontrollable and unpredictable. As a result, parents
are supposed to become more aware of the real risks. and, consequently,

they are supposed to use the child restraint devices more consistently.

Theoretically, this reasoning is sound. In practice, however. an
educational program based on risk perception theory could have the opposite

effect. Pieterse and colleagues (1992) have shown that many parents are
confronted with a completely different problem. Most parents did buy a

child restraint device with the intention of using it. So, parents seem to

be aware of the risks. One-third of the parents, however, stopped using the
child restraint device because their child got extremely restless and
annoying. These parents are confronted with a dilemma. On the one hand.
they are familiar with the risks. On the other hand. they do not know how

to handle their child who does not want to be put in the child restraint
device. An educational program emphasizing, again, the risks of not using a
child restraint device, may only lead to more stress among parents. What

may help these parents is advice on how to handle their child in this
situation. Moreover, it may be useful to look at product innovation and to
develop child restraint devices that are better liked by children.

This case may illustrate that a social psychologist whose primary interest
is testing risk perception theory in an applied setting may not contribute
much to practice. The case represents an interesting application of risk
perception theory, but the theory does not contribute fruitfully to the

solution of the problem in question. The case illustrates that applying
theories to practical problems may go wrong when researchers use a monotheoretical perspective as a starting point instead of the problem in

question.

10

Of course, risk perception theories may be helpful in other practical
cases. For instance, Linville and colleagues (1993) describe how people's
risk estimates are influenced by the so called under-accumulation bias:

small risks associated with one-time risk behaviours are systematically
underestimated when the same behaviour is performed frequently. Applied to
condom use and condom failure, even if people use condoms hundreds of

times, estimates of the chance of failure of one in a hundred are still

very low. Linville and colleagues suggest that people are very likely to
show this bias in the case of protective measures, such as condom use. This

case illustrates that risk perception theory does help us understand why

people do not change their behaviour when risk information is given as one
time risks, while in reality the behaviour in question is performed more

often. Current AIDS education is still providing information about the
failure rate of condoms as failure chances for a single sexual contact. We
now better understand why this kind of information has so little effect.

Moreover, the theory suggests practical suggestions for improved

educational messages that will be processed with less bias. such as
examples of cumulative risks.

Disadvantages of a mono-theoretical perspective: Causal Attribution

Weiner's (1986) attribution theory of motivation and emotion describes the
interrelationship of the causes of events people distinguish and their

■c;iibsegilent behaviour. According to this theory, people make attributions

with respect to events happening to themselves, and also with respect to
events happening to others. Especially negative events do initiate causal

attributions (Weiner, 1986). As such, a disease will initiate causal

attributions for the onset of the disease among both actors (patients) and
observers

(people from the patient's environment).

According to Weiner's theory, attributions first cause an emotional.

response (or attitude) followed by a behavioural response towards the
person. Attributions linked to uncontrollable and/or external causes
11

*

usually result in positive emotions and behaviour. whereas attributions

linked to controllable and/or internal causes usually lead to negative
emotions and behaviour. Applied to a patient, this implies that an observer
will make external/uncontrollable or internal/controllable causal

attributions to the disease. Subsequently, these attributions determine a
positive or negative attitude towards the sick person, which may finally

result in a willingness or an unwillingness to provide assistance. respec

tively (Weiner et al., 1988).

As for the problem of stigmatization of people with AIDS, the theory states

that people who are confronted with a person with AIDS will first make
causal attributions for the onset of the disease. For example, they may

think that the person has contracted HIV because of promiscuous sexual
behaviour, and they may consider this cause as being controllable and
internal. According to the theory, these attributions will initiate

feelings of contempt rather than sympathy, finally resulting in a low

willingness to provide assistance. However, people might also think that
the person contracted HIV through contamination in a hospital, for example

during a blood transfusion. In this case, they may make uncontrollable and
external attributions, which. in turn, may evoke pity and a willingness to
assistance. Several authors have shown that these theoretical predictions

partly can be proved in practice (Peters et al., 1994 ; Schaalma et al.,
1993b; Weiner et al.. 1988). The more people attribute AIDS to internal
and/or controllable causes rather than external and/or uncontrollable

causes, the more negative are their responses to people with AIDS.

This case is an interesting example of applying a single theory to a

practical problem. The question is, however, whether this theoretical
approach is useful for solving the problem of stigmatization of people with

AIDS and people who are HIV positive. Taking Weiner's theory as a point of
departure, a logical step to reduce stigmatization would be motivating
people to consider the cause of HIV infection as uncontrollable and

external. Communicating such a message. however, may imply a serious

problem because it is in contradiction with current AIDS prevention
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♦

programs emphasizing that HIV infection can be prevented by taking selfresponsibility . In other words, current AIDS prevention programs emphasize

that causes of HIV infection are controllable and internal. So, although
application of Weiner's theory provides a better understanding of the

process of stigmatization of AIDS patients, it does not provide a feasible
solution to reduce the problem.

Weiner's theory. however, is just a single theory and there may be other
theories that enable health educators to understand and solve the problem.
For instance. emotional responses can be compared with attitudes, and the

relationship between emotions and responses can be compared with the

relationship between attitudes and behaviour. Several theories about
attitudes and behaviour, for example the Theory of Reasoned Action
(Fishbein & Ajzen, 1975; Ajzen, 1988), have shown that attitudes towards a
behaviour are the result of balancing all advantages and disadvantages

associated with the behaviour. Thus, apart from attributions. the attitude
and behaviour towards people with AIDS will be determined by other
variables as well. In this respect, -it seems obvious to take attitudes
towards sexual promiscuity and homosexuality into consideration. People
with an unfavourable attitude towards these issues may also be negatively

predisposed towards AIDS patients. Another model of behavioural

determinants, the Health Belief Model (Janz & Becker, 1984), marks the

importance of health beliefs, or risk perceptions, thus arguing that the
risk perception of contracting AIDS when helping a person with AIDS or

people who are HIV positive may form a barrier. Peters and colleagues

(1994) indeed found that people with a negative attitude towards sexual

promiscuity and homosexuality do have a negative attitude towards people
with AIDS, and. in addition, show little tendency to provide assistance.

Furthermore, they found that people who are afraid to contract AIDS through

providing assistance to people with AIDS have low intentions to provide
assistance.

These explanations seem to provide a better pretext for a solving the
problem of stigmatization than the attributional explanation. For example.
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a health education campaign may be developed which stimulates the
acceptance of promiscuity and homosexuality, carefully explaining that

infection through social contact with AIDS patients or HIV-positives is
impossible. Although we do not know for sure whether such an approach
actually will reduce stigmatizing, the broader theoretical framework has

increased our perception of potential solutions.

Multiple theories may be useful

Theories can be very useful from a practical point of view. A one-sided

focus on one. or only a few theories, however. can lead to suggestions that
may not contribute to a reduction or solution of a practical problem. or

that even may be counterproductive. The examples of risk perception theory
and attribution theory demonstrate that a thorough analysis of the

practical problem is a first and essential step in applying socialpsychological theories to solve practical problems. Researchers should not

restrict themselves to one social-psychological theory, but they should
consider all aspects of the problem. Before potential theoretical

frameworks are selected, we have to answer questions such as: what is the
problem, why is it a problem, whose problem is it, what are possible

causes? A careful analysis of the practical problem may prevent spending

time on irrelevant theories, irrelevant problems, or problems that are not
social psychological and that need approaches from other disciplines.

A second important aspect of problem-driven applied social psychology is

the selection of appropriate theories. To find out whether a theory is

relevant for a given practical problem, we have to specify the conditions

1) that allow the theory to make predictions (McGuire, 1991), and 2) that
are necessary for theoretical concepts to be relevant (cf. Ajzen, 1988, p.

138-142). More than in fundamental and theory-driven applied social
psychological research, problem-driven applied social psychology assumes

that, given empirical support, multiple theories may be useful within the

conditions that limit the application of the theory.
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*
♦

Veen (see Kok, 1993) describes three strategies for the selection of
theories that may be appropriate for reducing or solving a particular
practical problem: a) the issue-related strategy,, b) the concept-related

strategy, and c) the general-theory strategy. These strategies will be
illustrated with the above mentioned problem of child restraint devices.

The issue-related strategy for the selection of theories refers to a search

for theories or insights that are specifically tailored to the problem in
question. With regard to the problem of child restraint devices, there were

some foreign studies, but most of these were from a sociological
perspective. The second focus of the issue-related strategy is on theories

or insights directly related to the problem. With regard to the problem of
child restraint devices this may lead. for instance, to theories concerning

safety, risks, risk-protection. and so on. such as protection motivation
theory (R.W. Rogers, 1983), the health belief model (Janz & Becker, 1984),

or the precaution-adoption model (Weinstein, 1988).

The concept-related strategy for the selection of theories reflects a
selection process that is based upon the translation of specific problem

related concepts into more general explaining principles. According t^ this

strategy, researchers should start with the formulation of preliminary

explanations for the problem in question. Subsequently, abstracting from
specific problem-related concepts may lead to general concepts that are

linked to theories. With regard to the problem of child restraint devices.

preliminary explanations for the low use of child restraint devices were.
for instance: a) parents might have a lack of knowledge about the
advantages of child restraint devices; b) parents might underestimate the

risk of car accidents; and, c) low use might be due to practical barriers
(e.g. financial costs). Weighing safety against practical barriers leads to
attitude models, such as Ajzen's (1988) Theory of Planned Behaviour. This

theory leads to two other theoretical concepts: social norms and perceived
behavioural control or self-efficacy. Although none of the preliminary

explanations was related to these two concepts, both could be relevant on
second thought.

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When both afore mentioned selection strategies do not lead to specific

theoretical insights, we have to rely on general theories to formulate
explanations for the problem in question. With regard to the child

restraint devices, McGuire's (1985) persuasion-communication model suggests

seven explanations for educational programs being ineffective: 1) people

may have never heard of the program; 2) people may not have understood the
program; 3) the program may not have been convincing enough; 4) a subject's
partner may not agree with the educational implication; 5) it may be too

difficult to change behaviour; 6) people may have forgotten the program;

and, 7) people may have tried to change their behaviour, but they did not

like it. Although we already were familiar with some of these explanations.

this general selection strategy did lead to other theories that may be

relevant, such as relapse prevention theory (Marlatt & Gordon, 1985)
suggesting that parents should receive support to continue child restraint

devices use, especially after negative experiences.

Although these strategies are theoretically different, in practice
researchers should preferably merge the three perspectives when solving a
practical problem. The use of all three strategies. instead of the use of
only one strategy, may result in a more comprehensive understanding of the

problem and potential solutions.

3

Psychosocial behavioural determinants

Theories of behavioural determinants

At different phases in the health education planning process theories are

used. The first phases, focusing at the analysis of the health problem.
rely primarily on epidemiological theories. The phases focusing at the

development of health promotion programs rely heavily on theories from the
behavioural sciences, especially social psychology. The present and the

next two paragraphs will describe general and specific theories that can be
applied in the diagnosis of behavioural determinants, options for the

intervention program, and program implementation.

16

<

The educational diagnosis addresses the understanding of the reasons people

have for their behaviour: why do people behave as they do. A model that has

been used in a wide range of health related contexts is the Health Belief
Model (Becker, 1974; Janz & Becker, 1984). The basic components of the HBM
are based upon psychological expectancy-value models hypothesizing that
human behaviour depends mainly upon the value placed by an individual on a

particular goal, and upon his or her estimate of the likelihood that a
given action will achieve that goal. With respect to health: the desire to
avoid illness or to get well, and the belief that specific behaviour will

prevent or reduce illness. More specifically, the HBM consists of four

psychological variables (Janz & Becker, 1984): 1) perceived susceptibility,
referring to one's subjective perception of the risk of contracting a
particular condition or illness; 2) perceived severity, referring to

feelings concerning the seriousness of contracting an illness; 3) perceived

benefits, referring to beliefs regarding the effectiveness of various
actions available in reducing the disease threat; and 4) perceived

barriers, referring to potential negative aspects of a particular health
action. In other words, an individuals decision to engage in a health
action is determined by his or her perceptions of personal susceptibility

to, and the severity of, a particular condition of illness. The specific

action taken is based upon a kind of cost-benefit analysis of perceived

benefits and barriers. According to the HBM, this decision making process
is triggered by a 'cue to action' which might be internal (i.e. symptoms of

a disease) or external (e.g. health education).

Although an impressive body of research findings has linked HBM dimensions
to health actions (see for overviews Janz & Becker, 1984; Harrison et al..
1992), recent research has demonstrated the importance of factors which

were not specifically developed or examined in the context of health
behaviours. FOr example, many health-related behaviours are undertaken for

reasons for what are ostensibly nonhealth reasons, suggesting that people's

cost-benefit analysis should also included benefits other than health

beliefs. Current general social-psychological models suggest that an
individual's behaviour, including health-related behaviours, is also

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determined by perceptions of normative or social influences (Ajzen &

Fishbein, 1980) , and by a conviction that he or she can successfully

execute the behaviour required to produce specific outcomes (Bandura, 1977;
1986) .

Various general social-psychological models predicting goal-oriented
behaviour can be applied to health-related behaviours. Although these

models include a broad range of variables, basically three general

categories of behavioural determinants can be distinguished (Ajzen,

1988 ;

Bandura, 1986):

■ Attitude: beliefs and evaluations about advantages and disadvantages
(e.g. health risks) of behaviour resulting in an attitude about the
behaviour, also referred to as outcome expectations. Examples of specific
theories within the attitude area are theories of risk perception (Van der
Pligt et al., 1993; Weinstein, 1988), and anticipated regret (Richard et

al., 1995). Other theoretical concepts that may related to the attitude
construct are personal norms, also referred to as self-identity (Sparks &

Shepherd, 1992) or role-identity (Theodorakis, 1994), and moral norm, also
referred to as personal normative beliefs (Manstead & Parker, 1995; Valois

et al., 1988).
■ Social influence: subjective beliefs about social norms and expectations.

also referred to as injunctive social norms (Fishbein & Ajzen, 1975;

Cialdini et al., 1990); observed behaviour of others, also referred to as
modeling (Bandura, 1986; De Vries et al., 1995) or descriptive social norms

(Cialdini et al., 1990); and direct social pressures (De Vries et al..

1995; Evans et al., 1978). Examples of specific theories within the social

influence area are theories of social comparison and social support (Taylor
et al., 1986) .
■ Self-efficacy: beliefs about perceived behavioural control. or self-

efficacy expectations. Examples of specific theories within the selfefficacy area are theories of attributions and success-expectancies

(Weiner, 1986).

These three categories of behavioural determinants can be seen as social

18

«

cognitive perceptions, predisposing factors, which have to be distinguished

from reinforcing factors (e.g. actual social support) and enabling factors
(e.g. actual skills or facilities)(Green & Kreuter, 1991). Ajzen (1988) and
Bandura (1986) call attention to the potential discrepancy between

perceptions of social norms and actual norms, and between perceptions of

self-efficacy and actual skills or barriers. Improving people's selfefficacy for healthy behaviour through health education should be combined
with lowering barriers that hinder healthy behaviour through health
promotion.

Figure 1 presents a representation of a general model for behavioural
determinants including attitudes, social influence, self-efficacy, actual

skills. and facilities (actual, ncn-psychological barriers).

<< insert Figure 1 about here >>

Models of behavioural determinants do not imply a unidirectional influence;
attitudes. social influence and self-efficacy can be consequences as well

as antecedents of behaviour (Zimbardo & Leippe, 1991). Educational programs

try to change behavioural determinants in order to change behaviour. but,

when possible, also techniques are used that influence behaviour rather.
directly, such as commitment procedures and systematic experiences with the
behaviour followed by feedback and reinforcement. Positive experiences with
behaviour may in turn change psychosocial determinants of behaviour, thus

creating reciprocal determinism (Bandura, 1986).

The next sections will present two studies on determinants of behaviour in

the areas of smoking prevention and AIDS prevention. Both examples will be

continued in the paragraphs on intervention development and implementation.
A problem analysis of cancer and cardiovascular diseases showed that

preventing the onset of smoking among young people is highly relevant for
the prevention of both diseases. A problem analysis of AIDS showed that,
while young people are not a risk group in terms of high prevalence, the

promotion of condom use by young people at the onset of sexual behaviour
19

may make a significant contribution to AIDS prevention.

A protocol for measuring and analyzing behavioural determinants

For the development of planned health education programs. it is necessary
to understand the determinants of the target behaviour for the target

population. Often, that understanding is lacking or incomplete. In general,

a combination of qualitative and quantitative techniques is used to measure
and analyze the determinants of behaviour (De Vries et al., 1992). The

atti tude/socia.1 influence/self-efficacy model serves as a guideline for the
development of interviews and questionnaires. First, the target behaviours
and the target group have to be specified. Then relevant beliefs or outcome

expectations, relevant reference persons, and relevant self-efficacy

expectations have to be identified.

The first phase in measuring determinants involves a survey of the
available theoretical and empirical literature on the target behaviour or

related behaviours. This will provide initial ideas about the relevant

determinants. In the second phase. a qualitative method is used to find o”t
the target population's own ideas about determinants of their behaviour.
through individual open interviews, group interviews or open-ended
questionnaires. The initial ideas that arise in the first phase serve as
possible cues for the interviews. In this phase intermediates or experts

can also be questioned. The third phase involves a quantitative method. a
structured questionnaire with questions that are based on the results of

the qualitative phase and that is administered to a large sample of the
target population.

The main focus of the analysis of the questionnaire data is on finding
(differences in) psychosocial behavioural determinants distinguishing

groups of the target population that do or do not perform the target
behaviour (for instance, smokers versus non-smokers, young people consistently using a condom versus those who do not) . The analysis can also be

20

<

directed at differences between people with positive and people with
negative intentions, especially when considering behaviour that is not, or

not yet, common in the target population. While these differences between
groups are most informative, the absolute scores may provide information on

biases or misunderstandings that are shared by all groups and that may need
to be changed. The people who tried to adapt a new behaviour but then
returned to their former behaviour. are a very interesting group to study.

In this particular analysis the negative outcomes of, and barriers for. the

desired behaviour change become clear. Finally, the influence of other
potentially relevant variables can be studied, such as gender, age, SES, or
experience with the behaviour.

Measuring and analyzing determinants of smoking

De Vries and colleagues analyzed the determinants of the onset of smoking

in young people in a series of cross-sectional and longitudinal studies (De
Vries & Kok, 1986; De Vries et al., 1988; 1990; 1992; 1994; 1995). All

studies used a combination of qualitative and quantitative data-gathering

techniques (cf. De Vries et al., 1992). The 1986 study was based upon the

Theory of Reasoned Action (Ajzen & Fishbein, 1980); all other surveys were
theoretically based upon the attitude/social influence/self-efficacy model.

These studies provided detailed information on the attitudes, social
influences, and self-efficacy expectations of Dutch smokers and non-smokers

aged 10 to 15.

In their 1986 study, young people aged 10 to 15 were asked about smoking.

non-smoking and regular smoking in interviews or open response
questionnaires to elicit salient beliefs, salient normative beliefs and

intentions (De Vries & Kok, 1986) . Based on this eliciting procedure a
questionnaire was developed which consisted of: beliefs and evaluations of

28 consequences of smoking (e.g.

'If I (should) smoke, this is very

sociable -- very unsociable.'); normative beliefs and corresponding
motivations to comply with respect to 16 social referents (e.g. mother.

21

>

father, brothers, sisters, friends, classmates); and, 13 intentions
regarding both initial and regular smoking (e.g. regarding smoking with

friends, at parties, with parents, at school). In addition, the
questionnaire included: direct evaluations of smoking ('smoking is
bad/good, pleasant/unpleasant'); a general assessment of the subjective
norm ('most people that are important to me think that I should/should not

smoke'); and, items about experience of initial smoking, smoking status.

smoking consumption, age, and sex.

The results of this study supported the relations as suggested by the
Theory of Reasoned Action. For both attitude and subjective social norm the

composite indexes were significantly related to the general assessments.

r=0.61, pcO.OOl, and r=0.34, p<0.001, respectively. The correlations of the
composite indexes of attitude and the subjective social norm with the
intention were r=0.61, p<0.001, and r=0.50, pcO.OOl, respectively. Together
these variables accounted for 40% of the variance in intentions to regular

smoking (R=0.63, pcO.OOl). Behavioural intentions were significantly

correlated with regular smoking, r=0.73, p<0.001.

In addition, the results of this study provided detailed information about

beliefs differentiating smoking and non-smoking youth (see Table 1). For
example, it showed that non-smokers were more likely to endorse that
smoking has consequences that are negatively related to health than smokers

(e.g. 'risk of cancer'.

'coughing',

'nausea',

'respiratory problems'). Non-

smokers were also more likely to endorse that smoking has other negative
consequences, such as 'a bad smell'.

'high expenses', and 'offending

others'. Smoking students were more likely to endorse several personal
advantages of smoking, such as 'sociable'.
way of showing-off' ,

'a nice thing to do',

'a good

'relaxing', and 'relieving boredom'. They were also

more likely to endorse the importance of conformity aspects, such as

'belonging to a group', and 'doing what others do' . Furthermore, the study
showed that non-smoking students were more likely to perceive negative

subjective norms towards smoking than smoking students, among others from
their parents, relatives. friends and classmates. The negative influence of

22

*

direct peer pressure, however. was not as strong as might be expected. De

Vries and Kok suggest that young people may not want to admit social
influence and/or that they may not be able to recognize indirect social

pressures. The study also suggested that regular smoking was associated
more strongly with long-term disadvantages, such as health, while initial

smoking was more closely connected with short-term effects, both positive
(e.g. taste), and negative (e.g. irritated eyes).

<< insert Table 1 about here >>

In a second survey De Vries and colleagues (1988) considered self-efficacy

(Bandura, 1986) as a third determinant of young people's smoking inten-

tions. In this survey, assessments of attitudes, subjective norms and
intentions were based upon the 1986 questionnaire. Self-efficacy was

assessed by means of nine questionnaire items addressing students' ability
to refuse offers to smoke, to provide arguments against smoking. to resist

social pressures to smoke, and to stop smoking (see Table 2) . The results
of this study supported the idea that students' self-efficacy expectations

were strongly associated with their smoking intentions. r=0.66, p<0.001. An
hierarchical analysis of regression showed that attitudes accounted for 44%

of the variance in students' smoking intentions (pcO.OOl), and that

introduction of subjective social norms added 4% of variance accounted for

(p<0.05). Introduction of self-efficacy in the regression equation.
increased the proportion of variance accounted for with another 15%
(pcO.OOl). The study also showed that students' self-efficacy expectations,

after controlling for behavioural intentions, was directly related to their
smoking behaviour. Intentions accounted for 55% of the variance in
students' smoking; self-efficacy expectations for another 9%. According to
Ajzen and Madden (1986) this may be due to the fact that subjective

assessments of behavioural control do reflect actual behavioural control,

at least to some extent.

<< insert Table 2 about here >>

23

♦

Measuring and analyzing determinants of (un)safe sex

Schaalma and colleagues measured and analyzed the determinants of young
people's intentions to use condoms to prevent HIV infection (Schaalma et

al., 1993a). They too based their cross-sectional surveys on the
attitude/social influence/self-efficacy model. Questionnaire items

assessing attitudes, risk perceptions, subjective social norms, selfefficacy, and behavioural intentions were based on a survey of literature,
and on interviews with young people. youth workers and teachers. The

questionnaire was pretested among about 200 secondary school students.
Attitudes towards using condoms consistently for the purpose of HIV

prevention were indexed using a three-item zdirect' semantic evaluation.
and using an 'indirect' evaluation based upon beliefs about 22 personal
consequences of using condoms consistently, including health beliefs (e.g.
'Condoms reduce the pleasure of love-making'.

'If you want to use a condom

to prevent AIDS you distrust your partner'). Perceived personal
vulnerability was separately assessed using two items regarding the risk of

HIV infection when having sexual intercourse without using condoms. The
survey included two measures of social influence: subjective social norms

(injunctive social norms with parents, best friends. and partner as social
referents) , and perceived peer behaviour (descriptive social norm). Self-

efficacy was assessed using a set of 15 items referring to the degree to

which respondents considered themselves able to use condoms, to purchase
condoms, to carry them regularly, to negotiate condom use, and to maintain

condom use (e.g. "Do you think that you have the guts to buy condoms in a
drugstore?',

'Do you thing that you are able to bring up the subject of

condom use when

?'). The outcome variable of interest. intentions to

use condoms consistently, was indexed using a set of five items referring

to various situations (for instance. using condoms with a regular date,

using condoms when oral contraceptives are used). Together attitudes.
social influences and self-efficacy expectations accounted for more than

50fc in the variance in intentions to use condoms consistently (see Table
3) .

24

*

<< insert Table 3 about here >>

Their study provided detailed information about attitudes, social
influences, and self-efficacy expectations of Dutch young people aged 12 to
18 with respect to intentions to use condoms consistently to prevent HIV

infection (Schaalma et al., 1993a). The study also revealed relevant
differences between young people with different levels of experience with

sexual intercourse (see Table 4). With respect to attitudes towards using

condoms consistently the results revealed that most young people regarded
condom use because of AIDS as sensible and necessary. On the other hand.

they did not regard condom use as being pleasant. Young people with
experience of intercourse were the least likely to have a positive attitude
towards consistent condom use. Although they regarded using condom
consistently as being sensible, they did not consider it necessary to use

condoms consistently, especially when having intercourse with a relatively
well-known partner. Moreover, they were most likely to regard consistent
condom use as being unpleasant. In their opinion condom use means an
annoying interruption, reduced sensitivity, and reduction in pleasure.

These results indicate that. on the whole, young people endorse the
preventive advantages of consistent condom use and that these advantages

counterbalance the disadvantages, the unpleasantness of condom use.

However, when young people gain experience with sexual intercourse. the
disadvantages of consistent condom use seem to become more significant, and

the necessity of consistent use seems to become less significant to them.

<< insert Table 4 about here >>

With respect to social influences the study revealed that young people did
not perceive condoms use as current practice among their peers, although
perceived subjective norms with regard to using condoms consistently were

moderately positive. Perceived subjective norms of young people without
experience of intercourse were more positive than those of student with

experience of intercourse. When different social referents are considered.
the positive social influence of parents was striking and conflicted with
25

young people's tendency to become more independent of adults and to conform

with their peer group (cf. Conger, 1977).

With respect to self-efficacy, the study showed that young people did
expect difficulties regarding their ability to purchase condoms, to carry
them regularly, to use them consistently, and to negotiate the consistent
use of condoms with a (potential) sex partner. Young people without

intercourse experience were most likely to expect difficulties with the
purchase of condoms and with carrying them regularly. Young people with
experience of intercourse were most likely to expect difficulties with the
maintenance of consistent use with a relatively well-known partner. Young

people who did not form a habit of condom use were more likely to have low

self-efficacy expectations regarding (the maintenance of) condom use, and
regarding their communicative skills to negotiate condom use with a wellknown sex partner.

4

Health Education Interventions

Theories of behaviour change through communication

Current general social psychological models of behaviour change distinguish
steps, phases or stages of change. Within those steps, various specific

theories can be applied. One general framework for theories of behaviour
change is provided by McGuire's (1985) persuasion-communication model. This

model describes the various steps that people take, from the initial
response to an educational message to, hopefully, a continuous change of
behaviour in the desired direction. This framework was simplified and

extended into seven phases (Kok, 1991): successful communication (attention
and comprehension); changes in behavioural determinants (attitude, social

influence, self-efficacy) , and behaviour; and maintenance of behaviour

change. Interventions may be different for each phase, and the decisions
that have to be made about categories of communication variables (message,
target group, channel, and source), may be different too and may even
26

conflict.

Prochaska and DiClemente's (1984) stages of change model distinguishes
stages of change within the person: pre-contemplation, contemplation.

preparing for action, action. and maintenance or relapse. Their model does
not refer to the communication process, but the similarities between this
model and McGuire's model may be evident. An important contribution of the

stages-of-change model is the specific tailoring of educational efforts to
groups of people in different stages of change. Interventions based on this
model normally have completely different methods or strategies for each

stage.

One general theory, or theoretical framework, covering both determinants of

behaviour and the process of behaviour change is Bandura's (1986) social
cognitive theory (SCT). In SCT the relationships between cognitive.
environmental and behavioural variables are seen as interactive and bi

directional . Reinforcement of behaviour is a key environmental factor
studied by social cognitive theorists. Other people in the environment can

also affect behaviour because a person learns through observing others and

receiving reinforcement. The SCT cognitive variables include outcome
expectations and self-efficacy expectations. Modelling and incentives are
SCT's major intervention methods for influencing behaviour.

Within these general frameworks, a number of other theories can be applied

(Glanz et al.. 1990; Zimbardo & Leippe, 1991). For instance. to motivate
people for change, theories of risk perception (Van der Pligt et al.. 1993;
Weinstein, 1988) can be applied. To accomplish attitude change. theories

about fear-arousal (R.W. Rogers, 1983; Leventha1, 1984; Janz & Becker,

1984), elaboration likelihood (Petty & Cacioppo, 1986), and persuasive
communication (Burgoon, 1989; McGuire, 1985) may be useful. Theories about

social comparison theory (Suls & Wills, 1991), group polarization
(Isenberg, 1986), and social inoculation (Evans et al., 1984; 1991) may be

useful for dealing with social influence. To help people maintain their

behavioural change, theories of attributions (Hewstone, 1989), re27

attributions (Fdrsterling, 1988)z and relapse prevention (Marlatt & Gordon,
1985) can be applied. Although these theories often cover only some steps.

or even only parts of steps, they can be helpful in developing
interventions that focus on particular aspects of change.

Recently two dual process theories of persuasion have increasingly been
used in research on persuasion-communication, especially attitude change

(Eagly & Chaiken, 1993). An implicit assumption of many health educators is
that receivers do actively process the message (McGuire, 1985). However,

the Elaboration Likelihood Model (Petty & Cacioppo, 1986) and the

Heuristic-Systematic Model (Eagly & Chaiken, 1993) both argue that not all
receivers are equally interested in the message. Sometimes people have a
strong tendency to elaborate, i.e. they tend to think carefully about the

message arguments (central route or systematic processing). In other

situations they show less tendency to elaborate and are more responsive to

peripheral cues such as the source. the form of the message and the
behaviour of others (peripheral route or heuristic processing). Changes in
attitudes and behaviour brought about through the central route are likely

to persist longer than changes via the peripheral route. From these

theories we can understand why health education messages do not have the
desired effect, because the receivers do not process our carefully

developed message. Moreover, we can derive that health educators should try
to encourage central processing both by motivating receivers to think and

by building receivers' skills for information processing (Petty & Cacioppo,
1986) , by means of methods such as enactive learning and participation
(Bandura, 1986). For example, participating in role playing affects the
attitude of the active participant more than that of passive observers.

This effect has been demonstrated only in situations in which participants
dispose of sufficient time, information and abilities to actually elaborate

(McGuire, 1985).

28

A protocol for developing theory-based and data-based health education

programs

The stage following the analysis of behavioural determinants is the stage

addressing the development of the health education program. In this stage
insights from theory and research have to be translated into educational
methods and strategies. A shift must be made from explaining behaviour to
changing behaviour. There is no such thing as a magic bullet: an

intervention method that is universally effective (Mullen et al., 1985).

Intervention programs have to be tailored very carefully to the behaviour,
determinants, and target population (Bartholomew et al., 1991; Parcel et

al., 1989b; Schaalma & Kok, 1995; Schaalma et al., 1994). On the basis of a
careful review of the available literature and research, on the application

of theories, and on additional empirical data. a number of steps have to be
taken. The steps include:

1. The formulation of educational goals in terms of determinants, e.g.
enhancing self-efficacy.

2. The specification of educational or learning objectives (indented
learning outcomes) indicating what the target population is supposed to

learn, e.g. skills for resisting social pressure from peers.

3. The selection of appropriate methodologies that fit with the objectives.
e.g. modelling. A wide variety of theories and empirical data is available

for this purpose, all relating to changing behaviour through communication.

In this step McGuire's (1985) persuasion-communication model can serve as a
checklist.

4. The translation of methodologies into feasible strategies and material,

e.g. role playing activities, videotaped role video modelling. Although
theories may suggest methodologies, the translation of methodologies into
actual educational strategies and materials requires practical experience.

creativity and thorough pretesting.
5. The anticipation of implementation barriers, e.g. training of
intermediates. Potentially effective educational programs will not have any
effect if they are not used or are used incorrectly. Collaboration with

potential future users of the program is essential here.

29

6. The monitoring and evaluation of process and effect of the educational

program at different moments during the development.

Developing programs for smoking prevention

De Vries and colleagues developed a smoking prevention program for
secondary school students, aged 13 and 14, following McGuire's persuasion
communication model and using insights from other, more specific theories

(cf. De Vries & Kok, 1986) . In terms of goals derived from the determinants
study, the program tried to enhance the salience of the advantages of non
smoking and the disadvantages of smoking. to increase the resistance to

social pressure to smoke, and to increase self-efficacy expectations about

non-smoking in combination with the necessary skills. With respect to
attitudes, specific learning objectives were: students should be able to

recognize short- and long-term advantages of non-smoking and disadvantages

of both regular smoking and initial smoking, and they should be able to
cope with false arguments that smokers use to justify smoking. Specific

learning objectives concerning social influence were: students should be
aware that the majority of people do not smoke. and are against smoking;

they should be able to recognize direct and indirect pressures to smoke;
and. they should be able to resist pressures to smoke. Specific learning

objectives related to self-efficacy were: students should have the skills
to resist direct and indirect social pressure to smoke and to cope with
challenging situations. In this case, the learning objectives for the

social influence and self-efficacy determinants do strongly overlap.

Specific behaviour change and maintenance objectives were: students should
commit themselves to, and be reminded of their non-smoking intentions.

The selection of educational methodologies for achieving the desired
learning objectives was strongly based on the existing literature on
smoking prevention and on behaviour change through communication (See Table

5) . The transfer of information and the training of skills were primarily

supposed to be realized by peer modelling. In translating this learning
30

e

methodology into a practical strategy, collaboration with teachers and

students, in combination with careful pretesting, led to the development of

a peer-led program on video with small group activities and active
learning.

<< insert Table 5 about here >>

The program included five lessons. The first lesson provided a general

introduction briefly discussing the consequences of smoking and direct and
indirect peer pressure. During the activities students discussed reasons

for smoking and non-smoking, and possible ways to refuse cigarettes. The

second lesson focused mainly on the short-term effects of smoking,
including passive smoking. Some short-term effects were demonstrated by

tests on video, such as trembling and temperature of the hands, heart rate.
and the amount of tar. Other effects, such as the costs of smoking, were

discussed on video in interviews and in short scenes acted out by young
people. The third lesson discussed peer pressure and it included activities
aimed at recognizing and handling direct pressure. Several refusal

strategies were modelled on video and were practiced afterwards by role
plays in small groups. The fourth lesson addressed indirect pressure from

advertisements and adults. The activities focused on interpreting
advertisements and on alternative behaviours for realizing positive
outcomes of smoking. The last lesson provided a summary. The activities

centered on skills training, decision making and on commitment by students

to non-smoking. The individuals' own responsibilities were discussed and

commitment was increased by asking students to conclude a non-smoking
contract and to write their name on a public non-smoking poster. As a

reward, non-smokers received an attractive non-smoking poster and button.

The smoking prevention program was evaluated as attractive by students and
teachers. The alternation of video and activities prevented boredom. The
video-led nature of the program increased chances of implementation.
because teachers did not have to follow time-consuming training sessions.

This made it also possible to implement the program in lessons of different
31

9

disciplines in the school. Through the activities students could integrate
information within their life-style. Students' evaluation of the assistance

by the teacher was strongly related to their evaluation of the program.
indicating the importance of teacher motivation.

The effects of the smoking prevention program were assessed in a quasi-

experimental study using a pre-test and post-test control group design (De

Vries et al., 1994). Fifteen secondary schools were matched on pretest

smoking, school type (schools for lower secondary education versus schools
for higher secondary education), school size, and urban versus rural.
Subsequently, pairs of schools were randomly assigned to the experimental

or control condition. Four schools for lower, and five schools for higher
secondary education received the smoking prevention program. The no

treatment control group consisted of three schools for lower, and three
schools for higher secondary education. Students in both conditions had to

complete a pretest questionnaire one month before the smoking prevention

program was implemented. A first post-test questionnaire was completed six
months, and a second post-test questionnaire nine months after
implementation of the program.

The results of the evaluation showed that the program had a significantly
favourable effect on experimental smoking. The proportion of students who

started smoking was significantly lower in the experimental condition than
in the control condition (41.7% versus 52.1%; p<0.01). Furthermore, the

evaluation showed that the effects of the program on regular smoking varied
significantly between school types. Among students in schools for lower

secondary education (vocational schools), the proportion of regularly

smoking students increased with 7.1% in the experimental condition versus
14.1% in the control condition (p<0.01). No significant program effects

were found for students in schools for higher secondary education.

Although the smoking prevention program resulted in some positive effects.

these effects were rather limited and pertained to a relatively small
percentage of the two types of schools. Furthermore, there was evidence of

32

increases in knowledge, but few changes in attitudes were found. Self-

efficacy expectations improved for students in the experimental group, but
more for smokers than for non-smokers. Since the social environment of

vocational schools was found to communicate a norm in favour of smoking. De
Vries and colleagues recommended that programs for this group should be

embedded in a broader health promotion approach addressing non-smoking
policies to reduce smoking behaviour of parents and school personnel.

Developing programs for AIDS prevention

Schaalma and colleagues (1994) developed an AIDS and STD prevention program

for students of schools for lower secondary education, aged 13 to 15. The
educational goals of the program, based on the determinants study were: the
promotion and permanent establishment of positive attitudes towards the use

of condoms; the introduction of a positive norm with respect to safe sex
and the use of condoms; and. the enhancement of students' confidence with

regard to the actual implementation of the use of condoms. Specific

attitude learning objectives were: the improvement of students' knowledge
about HIV and HIV prevention; students should endorse the advantages of

condom use. among which personal short-term advantages that are not
associated with health (e.g. a lower chance of early ejaculations. the

avoidance of postcoital discharge of semen, the prevention of feelings of

regret); and. students should associate condom use with positive stimuli,
without becoming unrealistic. Specific social influence learning objectives

were: the education should clarify perceptions of group norms regarding
safe sex and condom use; and. students should be able to resist social
pressure to have unsafe sex. Specific self-efficacy learning objectives
were: the education should enhance students' self-confidence regarding

purchasing condoms, carrying condoms on a date, negotiating their use. and
using them adequately. Specific behaviour change and maintenance learning

objectives were: students should be provided with feedback. for instance
through communication with school counselors; they should also be
confronted with prompts, to remind them of their intentions; and they

33

opportunities to show the process of social influence, to introduce

positive role models, and to demonstrate dialogues concerning safe sex in

realistic risk situations. The video of the program deals with young
people's beliefs and values concerning safe sex, reasons for having unsafe

sex, barriers to practicing safe sex, communication about safe sex, and
resisting pressures to have unsafe sex. A first part of the video presents

shows a group of young people interviewing peers about safe sex, and

discussing these interviews. The scenes include, for instance, a condom
demonstration and a girl showing negative emotions after having been

pressed into unsafe sex. A second part of the video presents four scenes
concerning resisting social pressure. First, a realistic situation is

introduced, for instance a situation in which a boy is pressing his

girlfriend to have sexual intercourse. Halfway through the dialogue the
teacher stops the videotape and students are asked to finish the dialogue
in subgroups on the basis of specific questions. After discussion. the
video finishes with a happy ending. The dialogues. the viewing exercise and

the teacher instructions are guided by a framework for resistance to social
pressure (Evans et al., 1991): 1) say what you want, 2) adduce arguments.

3) stick to your opinion, 4) present alternatives, 5) give counter
pressure, and if that does not work, 6) walk away.

A pilot version of the program was pretested by means of interviews with

teachers and educational experts. These interviews addressed the
suitability and feasibility of teaching strategies, and examined

expectations about how long preparation and instruction would take. These
interviews revealed that the proposed strategies were too radical, and the

discrepancy between proposed teaching strategies and usual strategies was
shown to be too large, for example working in peer-led groups.
Consequently, the program was revised and a variety of strategies currently

in use were included in the final version. The student magazine was
pretested on students with regard to attractiveness, clearness, usefulness.

newsworthyness, persuasiveness, and closeness to real life. Although the
magazine was generally evaluated positively, the pretest led to changes in

content and style. A synopsis of the video. a concept scenario and the off-

36

line montage was pretested by means of group interviews with students with
respect to closeness to real life, attractiveness and credibility. Again,
pretesting led to changes and some of the scenes had to be recorded or

edited again.

The effects of the program were assessed in a field experiment using a pre

test and post-test control group design (Schaalma et al.. 1995).

Participating schools were matched in pairs on the basis of schooltype.
participating grade levels (9-10), religious affiliation, degree of
urbanization, number of participating students, boy-girl ratio, proportion
of ethnic minorities, and the qualifications of participating teachers.

Within these pairs schools were randomly assigned to the experimental or
the control condition. Experimental schools had to provide education about

AIDS, STDs, and prevention by using the experimental program; control
schools had to provide education about AIDS, STDs and prevention as

provided in the past years ('usual treatment').

Fiftyfour schools for lower general secondary education participated in the

study. Nineteen schools were catholic schools, 12 were protestant schools,
21 were non-religious schools, while two schools had a mixed religious
affiliation. Three schools were excluded from the analyses because they

failed to provide either baseline data or follow-up data. In sum. 77
teachers participated in the study; 39 were male. 38 female. Most of them
were teachers of biology (23%), health education (38%), or social studies

(19%). A pre-test questionnaire was completed by 3,142 students one month
before the program was implemented; a the post-test questionnaire by 2,786

students about two months after the implementation of the program. These
questionnaires were to a large degree similar to the questionnaire that was

used for the study on behavioural determinants that is described above
(Schaalma et al., 1993a). The final participating study sample consisted of
51 schools and all students whose pre-test and post-test questionnaire

could be correctly matched (N=2,430; 77% of baseline sample) . Matching
criteria were:

(1) school.

(2) class,

(3) date of birth,

(4) initials of

mother's name, and (5) profession of father. Unavailability for follow-up

37

was primarily due to absenteeism, transfer to other schools, or missing
data on matching variables.

The evaluation showed that, when compared with current AIDS/STD education

in control schools, the experimental program had a stronger favourable
impact on students' AIDS/STDs knowledge, risk appraisals, attitudes.

perceived social influences, self-efficacy expectations and intentions to
practice safe sex. When a sexual risk index was considered (varying from no

sexual intercourse to sexual intercourse with more than one sex partner

without using condoms), a differential program effect could be
demonstrated: the higher students' sexual risk at pre-test assessment, the
more they benefitted from the experimental program. Thirty-six percent of

the students in the experimental condition who reported inconsistent condom
use with one sex partner, and 45% of the students who reported inconsistent

condom use with two or more sexpartners at pre-test assessment, reported
sexual risk-taking at post-test assessment. In the control condition these
percentages were 45% and 52%, respectively.

To assess the effect sizes of the experimental curriculum, the observed
curriculum effects (difference between experimental and control change

scores) were converted to proportions of the standard deviation of the
measures employed. The results, presented in Figure 2, show that the
effects of the experimental curriculum were most pronounced within the area

of knowledge and attitudes, at the student level as well as at school
level. The effect of the education on students' risk appraisal, perceived
social influences, self-efficacy beliefs, intentions and risk-taking
behavior were smaller but still significant.

<< insert Figure 2 about here >>

A methodological limitation of this study pertains to the relatively short
time span between baseline and follow-up assessment (approximately 4

months). Such a short period limits the possibility to detect changes in

sexual behaviour, especially in a population of young secondary school
38

students of whom most are not yet involved in sexual intercourse. It also
limits the possibility to detect delayed and/or retention effects of the
experimental intervention. Longitudinal trials in which students are
observed over a longer period of time. preferably a number of years, are

needed. Schaalma and colleagues conducted a second follow up, approximately

4 months after the first'follow up. These data, however. are not yet
available.

5

Implementation of Health Education

Theories of implementation

Implementation of a prevention program is an essential part of the health
promotion planning process. If we do not ensure implementation. our work

has been largely wasted. School programs for the prevention of smoking are

useless if teachers do not use them. Underestimating diffusion and adoption

barriers is one of the reasons that health education is sometimes
ineffective. While the need for information about the determinants of

individual behaviour is commonly accepted, it is hardly recognized that

information about the determinants of institutional 'behaviour'

(such as

the adoption of a prevention program by organizations) is needed to for the
development of implementation strategies. The existing knowledge concerning
the diffusion and adoption of health promotion will be summarized from two

perspectives: features of the innovation that determine adoption. and the

importance of a 'linkage' system (Orlandi et al., 1990).

Classical research in the area of diffusion and adoption primarily focused
on associating adoption rates with innovation attributes (e.g. relative

advantage, compatibility, complexity, triability, and observability) and
characteristics of adopter categories (e.g. innovators, laggards)

(cf. R.W.

Rogers, 1983) . Although classical diffusion theory has contributed to our

understanding of the diffusion of innovations, it has been criticized from
different perspectives. One central criticism is that the classical model
39

is too narrowly focused on adoption, and that it fails to recognize that
' the adoption decision is only one step in a multistep process that ranges
from the first phases of innovation development to a point beyond adoption

at which the innovation either succeeds or fails in achieving a lasting and

meaningful impact'

(Orlandi et al., 1990, p. 291).

Consequently, the focus of contemporary research on the diffusion of school
health interventions has gradually shifted from innovation attributes and

adopter characteristics to teachers' planning behaviour and thought
processes and decisions with regard to an innovation process including four
subsequent stages: dissemination, adoption, implementation, and

continuation (Fullan, 1991; Kolbe & Iverson, 1981; R.W. Rogers, 1983).
Dissemination refers to the transfer of information about the innovation to
potential users (e.g. teachers). Adoption refers to potential users'

intention to use the innovation. Implementation refers to the actual use of

the innovation. Continuation refers to the stage in which the innovation

has become current practice. Within this approach, the classical innovation

attributes can be dealt with as subjective expectancies about advantages
and disadvantages of innovation adoption, implementation, and continuation.

respectively (cf. Paulussen, 1994; Paulussen et al.. 1994) .

According to Orlandi and colleagues many health promotion innovations have

failed because of 'the gap that is frequently left unfilled between the

point where innovation-development ends and diffusion planning begins'. as
if innovation-development barriers and diffusion barriers were aspects of
unrelated problems (1990, p. 294). To bridge this gap, Orlandi and

colleagues stress the need for a linkage system between the resource system
that develops and promotes the intervention (e.g. the Anti-Cancer Council),

and the user system that is supposed to adopt the intervention (e.g.
schools). Such a liaison group should include representatives of the user
system, representatives of the resource system, and a change agent

facilitating the collaboration. Diffusion of the innovation may be carried
out by any of the members of this liaison group. The essential point is
that the innovation-development process and the diffusion planning process

40

have been developed through cooperation, to improve the fit between

innovation and user, to attune intervention innovations to practical
possibilities and constraints, and to facilitate widespread implementation.

A protocol for theory-based implementation planning

A strategy to stimulate implementation should be based on a careful
analysis of the determinants of implementation behaviour, both on the
individual and organizational level. These determinants can be measured

with the same kind of protocol as is used in the determinants of behaviour
analyses, using the same kind of theories. such as social cognitive theory

(Bandura, 1986; see Parcel et al., 1989a; 1989b) and the theory of planned

behaviour (Ajzen, 1988; see Paulussen, 1994 ; Paulussen et al., 1994) .

Based on E.M. Rogers'

(1983) stages of innovation diffusion, most health

education implementation studies distinguish four phases: dissemination.
adoption, implementation, and continuation. The difference between these
phases and McGuire's steps or Prochaska & DiClemente's stages is not so
much the actual content of the phases but the level of the change target:

an organization instead of individuals. And even that distinction is

relative: health education interventions are sometimes directed at
communities, while implementation interventions are sometimes directed at

individuals, such as teachers or administrators.

The next step is the selection of methods and strategies to stimulate

implementation, recognizing the four phases: dissemination, adoption,
implementation and continuation. Again, the development of implementation

strategies follows the same protocol as the development of health education
interventions: goals, objectives, methodologies, strategies, implementation
and evaluation. Research in the area of intervention methodologies to

stimulate implementation by organizations, mostly based on social cognitive
theory (Parcel et al., 1989a; 1989b), shows the importance of modelling and

incentives, together with clear communication about specific implementation

41

procedures (Fullan, 1991), guided enactment and feedback, and coaching
during self-directed application of the innovation procedures (Joyce &
Showers, 198 8) . Adoption of health promotion interventions is facilitated

by observing other organizations adopt an intervention, as well as by reinforcement in terms of material incentives, social status, or the achievement of objectives.

Implementation of smoking prevention programs

Unfortunately, systematic implementation of health education programs.

supported by research is a rare phenomenon. Until now De Vries and
colleagues did not have the opportunity to develop and evaluate
implementation strategies for their potentially effective smoking
prevention program. One of the few examples of a well described

implementation research project is the implementation of Smart Choices, a

smoking prevention program, in more than 100 Texas school districts (Parcel
et al., 1989a; 1989b). The Smart Choices implementation strategies follow
the four phases mentioned above, and is strongly based on social cognitive

theory (Bandura, 1986):
■ Dissemination. The objectives are that teachers and administrators will

indicate awareness of the program, view the program favourably and

communicate with colleagues about the program. Methods to reach these
objectives are: personal communication by opinion leaders; using symbolic
modelling through a video and a newsletter (role-model stories).

■ Adoption. The objectives are that school districts will see the
advantages of the program in terms of outcomes, expectancies and social
reinforcements. The determinants study showed that the most powerful

incentives were: making a difference in the lives of students and meeting
the essential instructional elements mandated by the state. Methods to
reach these objectives are: symbolic modelling, incentives and social

contracting through the newsletter and an adoption form.
■ Implementation. The objectives are that teachers have the necessary

skills and self-efficacy to use the program with acceptable completeness.

42

e

fidelity and proficiency. Data from other implementation studies showed the
importance of in-service training. Methods to reach these objectives are:
direct modelling and guided enactment through a live workshop training, and
symbolic modelling through a video training.
■ Continuation. The objectives are that teachers and administrators will

have experienced positive feedback and reinforcement on the use of the
program after one year and will continue to use it. Methods to reach these
objectives are: social incentives through recognition; monetary incentives

through inexpensive reinforcers; status incentives through recognition and
designation; and self-evaluative incentives through a monitoring and

feedback system.

Part of the results of this implementation study are known. The

dissemination intervention program (a workshop for opinion leaders; a 12minute documentary style video and a newsletter. both based on symbolic

modelling) was evaluated using a pre-test and post-test quasi experimental
design with the school district as unit of analysis (Brink et al.. 1995).

School districts in two Texas education regions designated as intervention

regions received the dissemination intervention program (128 districts). A

third region was designated as a comparison group; districts in this region
(N=38) received a brochure announcing the availability of the •Smart

Choices' program. In intervention and comparison school districts teachers
and administrators completed questionnaires before and after the

intervention to assess changes in receptivity to tobacco prevention

programs. Administrators' and teachers' readiness to adopt smoking

prevention programs was assessed by means of questionnaire items referring
to characteristics of the programs (relative advantage; compatibility;
complexity), characteristics of the adopter (innovativeness; attitudes
towards tobacco prevention and tobacco policy; self-efficacy; outcome
expectancies), and characteristics of the environment (system support for

tobacco prevention; decentralized decision-making).

Among respondents to the 'readiness to adopt' survey in the intervention

regions, 31.7% of administrators and 28.8% of teachers recalled exposure to
43

•0

norms) , and their own capacity to use the information (self-efficacy) .
Because teachers* judgments were expected to vary across different

curriculum innovations, curriculum-related beliefs were specified for all
four AIDS curricula separately.

Teachers* adoption was conceptualized as their intention to use the AIDS
curricula during classroom-based HIV instruction. Intentions were expected

to gradually vary in strength; from absolute rejection to absolute
adoption. With regard to implementation, the extent of use and the level of

use was measured. Extent of use was indexed as the applied proportion of
all learning activities as proposed by a curriculum. The level of use index

consisted five hierarchically ordered descriptors representing partial use
of a curriculum, full use of a curriculum. and adaptive use of a curriculum

(i.e. full use but adapted to own and students* needs)(cf. Tillema et al..

1989).

Attitudes towards the four curricula were measured by means of items

addressing beliefs about the importance and feasibility of the learning

outcomes as prescribed by the curricula, personal benefits, financial

costs, and instrumentality (e.g. 'The time necessary for preparing
classroom instruction is acceptable'). Regarding subjective norms, teachers

responded to the perceived normative beliefs of students, the principal.

school board, colleagues, external consultants, and parents. Normative
beliefs were weighted by teachers' motivation to comply to these referents.

Self-efficacy was assessed by fourteen to seventeen items covering the
application of interactive teaching strategies, talking frankly about

sexuality, adaptation of AIDS content to own educational contexts. and
application of management strategies for creating a minimal level of

classroom orderliness and safety.

In addition to these variables, teachers also responded to questionnaire

items addressing: teachers* awareness-knowledge of the curricula; their
general ideological orientation towards education (student-centeredness);
their responsibility to teach HIV instruction; their sexual morality; their

46

r

attributions for the causes of students* risk-taking behaviour; schools'
formal AIDS education policy, the frequency of interaction with colleagues

about HIV instruction; their perceived consensus with colleagues about

goals and requirements for AIDS education; whether their colleagues were
using one of the curricula; and several demographic characteristics.

When the diffusion prevalence of classroom AIDS education is considered,

the study showed that about 73% of the teachers positively intended to

engage in classroom-based AIDS education during the next school year; 68%
were already involved in HIV instruction. while 62% of these teachers had

initially implemented at least one of the curricula. The curriculum
prevalence appeared to express a consistent decline, approximating about

40-60% of teachers in every next stage of the diffusion process. These

results are comparable to the average diffusion pattern of externally
developed curricula, indicating that generally about 50% of teacher do

receive curricula, while only 25% actively take notice of curriculum

content, and only 5-10% finally use the curricula in one way or another
(Paulussen, 1994).

Knowledge acquisition of the programs was mainly determined by diffusion
networks between teachers within schools. Teachers* intentions to provide
AIDS education in general was mainly determined by:

(1) subjective norms

(especially students, colleagues and school principal);

(3) sexual morality;

(4) sense of responsibility;

(2) self-efficacy;

(5) frequency of

interaction with colleagues about HIV instruction; and (6) the presence of
a formal school policy concerning AIDS education. Adoption of a specific
curriculum was. above all, related to perceived instrumentality (mainly

referring to teachers* need for clearly defined educational procedures and
to their concern about students* reactions to the proposed learning

activities), and with teachers* colleagues using one of the AIDS curricula
(descriptive norms) . The degree of implementation of the AIDS curricula was
most strongly associated with specific curriculum-related beliefs:

perceived instrumentality;

(2) subjective norms;

(4) self-efficacy.
47

(1)

(3) personal benefits; and

••

One of the most striking results of this research is that teachers'

innovation-decision making is hardly affected by perceived importance and
feasibility of student learning outcomes. This results are congruent with

research on teachers' planning behaviour and educational innovation in
general, indicating that teachers are concerned with procedural content and
approval or disapproval of their colleagues and students. rather than

specific student outcomes (cf. Clark & Peterson, 1986; Borko et al., 1990;

Hall & Hord, 1987) .

Paulussen and colleagues derived clear recommendations from their, and

other studies, with regard to the enhancement of widespread implementation

of school-based health education in general, and AIDS education in

particular. According to Paulussen and colleagues a school policy should

ate least combine:

(a) development of both theoretically and practically

validated intervention programs, using protocols as described in earlier
parts of this chapter;

(b) a focused promotion a available intervention

programs, both by mass media and face-to-face communication. based upon

social modelling;

(c) in-person assistance of teachers during classroom

implementation, including presentation of the rationale behind the

training, demonstration of good practice, opportunities for practice under
simulated conditions, non-evaluative performance feedback, and coaching

during self-directed application of acquired skills;

(d) development of

collegiality and school-level support through incentives, goal setting. and
embedding of the intervention in schools' formal policy; and empowerment of

the local linkage subsystem: local health or sex educators should be the

change agent in a linkage between schools and national resource systems.

6

Conclusions

Social psychology can be very useful in the field of health education and

health promotion. Social-psychological theories can be applied in the area
of health education for primary prevention of problems related to health.
48

«

Social psychology contributes to the diagnosis of psychosocial factors
determining health related behaviour, to the development of interventions

focused on changing these behaviour, and to the large-scale implementation
of these interventions.

The role of social psychology in the field of health education is referred
to as problem-driven applied social psychology. Problem-driven applied

social psychology is essentially different from theory-driven applied
social psychology. Whereas problem-driven applied social psychology refers

to using social psychological theories to solve or reduce a practical
problem, theory-driven applied social psychology refers to the testing of

theoretical ideas in practical settings. In our view problem-driven applied
social psychology is an important activity because it is the ultimate test

for the usefulness of social psychology as a discipline and profession.

The present chapter provided some examples of problem-driven applied social
psychology in the field of health promotion. It provided brief reviews of

the state-of-the-art, protocols and examples with regard to the analysis of

psychosocial determinants of health related behaviours, the development of
theory-based and data-based health education interventions, and theory

based and data-based implementation planning. It perhaps illustrated the
point that problem-driven applied social psychology is a not an easy

activity. An activity that needs a thorough knowledge of a broad variety of

theories, and that needs skills to select theories that may contribute to
the understanding and the solving or reducing of practical problems.

In our view, current social psychological practice does not include
problem-driven applied social psychology to a large extent. Hardly any

textbook on social psychology systematically addresses the issue of

applying theories. Most social psychological researchers are primarily
interested in testing theory, and, as such, most of them are quite mono
theoretical. Most social psychological practitioners lack the opportunities

and/or skills to apply social psychology systematically when dealing with

practical problems. And usually both researchers and practitioners lack the
49

skills to apply social psychological theory to practical problems.
Consequently, researchers frequently come up with irrelevant suggestions
and recommendations for practice. And practitioners frequently come up with
suggestions and recommendations that do not match theoretical insights. We

think that problem-driven applied social psychology should be

systematically developed and extended. Problem-driven applied social
psychology may be stimulated when respected journals on applied social
psychology request authors to address implications for practice, and when
these implications are evaluated with respect to their usefulness and

practicability.

50

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Schaalma, H.P. , & Kok, G.,

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Schaalma, H., Kok, G. , & Peters, L.

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Schaalma, H.P., Peters, L., & Kok, G.J.

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58

Schaalma, H.P., Kok, G.J., Bosker, R., Parcel, G., Peters, L., Poelman, J.,
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Schaalma, H.P., Kok, G., Poelman, J., & Reinders, J.

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Sparks, P., & Shepherd, R.

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Suls, J., & Wills, T.A.

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Taylor, S., Falke, R., Shoptaw, S., & Lichtman, R.

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Tillema, H.H. & Koster, A.J.

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60

Figure Captions

Figure 1: A general model for behavioural determinants including attitudes.
social influence, self-efficacy, actual skills, and facilities.

Figure 2: Effects of a Dutch school-based AIDS prevention program (Schaalma
et al./ 1995). Effect sizes at the student level are computed as the

difference between experimental and control student change scores divided
by the pooled SD for these students. Effect sizes at school level are

computed as the difference between experimental and control schools change
scores divided by the pooled SD for these schools.

-f/L •

61

1

Table captions

Table 1: Mean belief about, and evaluation of consequences of smoking

scores (range: -3/+3). Non-smoking youth (NS) versus smoking youth (S);
N=219 (De Vries & Kok, 1986).

Table 2: Reported mean scores of self-efficacy; comparison of smokers (S)

with non-smokers (NS)

(De Vries et al., 1988).

Table 3: Results of stepwise regression analysis on intended consistent

condom use to prevent HIV infection (N=1018)

(Schaalma et al., 1993a).

Table 4: Mean scores of determinants and intended consistent condom use:

students classified by their experience with intercourse (ranges in
parentheses)

(Schaalma et al., 1993a).

Table 5: The persuasion-communication program matrix adapted for smoking

prevention (De Vries, 1989). Each cell stands for a number of decisions
that have to be made, starting with the behaviour/message and
behaviour/receiver cells and then working back and forth. The program
matrix reminds the developer of the many different decisions that are

needed and may be incompatible with each other.

62

facilities

attitude

social influence

intention

behaviour

I

skills

self-efficacy

I

feedback

Figure 1: A general model for behavioural determinants including attitudes, social influence, self-efficacy, actual
skills, and facilities.

63

t

proportion of SD

1.3n

■

1,21,1 -

Legenda
student level

□ school level

1 0,9-

0,8-

0,70,6-i

1

0,50,4-

UjLj

-

0

knowl.

risk

beliefs norm model, effic.

intent, behav.

Effect sizes are computed as the difference between experimental and control student
change scores divided by the pooled SD for these students. Effect sizes at school level
are computed as the difference between experimental and control schools average
change scores divided by the pooled SD for these schools.

Figure 2: Effects of a Dutch school-based AIDS prevention program (Schaalma et al., 1995)

t
ir

Table 1: Mean belief about, and evaluation of consequences of smoking
scores (range: -3/+3). Non-smoking youth (NS) versus smoking youth (S);
N=219 (De Vries & Kok, 1986).

bad health
damage to lungs
risk of cancer
bad physical condition
coughing
irritated eyes
nausea
breathing problems
unwise
addictive
smells bad
expensive
passive smoking
offensive to others
sociable
tastes good
nice to do
relaxing
good for the nerves
discovering the taste
relieves boredom
satisfying curiosity
showing of
being pressed to smoke
doing what others do
belonging to the group
being pestered
feeling grown up

* p<0.05;

evaluations
S
NS

beliefs
S
NS

consequences

2.46
2.21
1.95
• 1.75
1.69
1.19
1.11
0.94
2.39
0.66
1.62
2.29
1.93
1.64
-0.54
-0.98
-0.56
-0.96
0.07
1.18
0.48
0.94
0.48
-0.33
1.52
0.25
-0.22
0.20

1.93**
1.71**
1.20**
1.20**
0.44**
0.12**
0.24**
0.22**
0.63**
0.32
0.22**
1.49**
1.44**
0.80**
1.34**
1.32**
0.95**
0.61**
0.71**
0.83
1.20**
0.32**
0.29
-0.54
1.27
0.44
-0.27
0.07

p<0.01

65

-2.52
-2.76
-2.77
-2.26
-1.66
-2.01
-2.09
-2.37
-1.94
-2.70
-1.82
-0.83
-2.30
-1.93
2.16
1.61
2.22
1.74
0.73
0.50
0.92
-0.34
-1.17
2.67
-0.92
0.56
-2.04
0.21

-1.46**
-2.07**
-2.80
-2.07
-1.83
-1.78
-2.20
-2.05*
-1.17**
-2.00**
-2.15
-0.49
-1.22**
-0.73**
2.54*
2.73
2.41
2.00
1.22
1.54**
1.24
0.49**
-0.63**
-1.34**
-0.05**
1.24**
-1.61
0.59

f
%
Table 2: Reported mean scores of self-efficacy; comparison of smokers (S)
with non-smokers (NS) (De Vries et al., 1988).

item

S (N=21)

NS (N=63)

When my friends smoke I find it very
hard/easy not to smoke.

-0.76

2.21

When I should wish to stop smoking, I shall
certainly/certainly not be able to do so.

0.30

1.31

When someone offers me a cigarette, I
certainly do/certainly don't know a reason to
refuse that cigarette.

-1.23

2.19

When my parents offer me a cigarette, I
certainly do/certainly don't dare to say no.

2.00

2.55

When I am offered a cigarette, I find it
difficult/easy to refuse.

0.23

2.57

For me it is very difficulut/easy to stay
(become) a non-smoker.

-0.77

1.41

When my friends offer me a cigarette, I
certainly do/certainly don't dare to say no.

2.15

2.75

When people call me a coward because I do not
want to smoke, I certainly do/certainly don't
know waht to say.

2.18

2.08

I find it very difficult/easy to explain to
others people that I don't want to smoke.

0.68

1.86

+3 = high self-efficacy towards non-smoking; -3 = low self-efficacy;
a = 0.80; * p<0.05

66

*

.

Table 3: Results of stepwise regression analysis on intended consistent condom
use to prevent HIV infection (N=1018; Schaalma et al., 1993a).

r
1 Attitude
2 Self-efficacy
3 Injunctive social norm
4 Vulnerability
5 Beliefs
6 Descriptive social norm

0.58
0.48
0.47
0.33
’ 0.44

0.34

all changes significant at beyond 0.01

67

R

R2

0.68
0.70
0.71
0.72
0.73

0.34
0.46
0.49
0.51
0.52
0.53

0.34
0.26
0.15
0.15
0.13
0.08

*
t

Table 4: Mean scores of determinants and intended consistent condom use:
students classified by their experience with intercourse (ranges in
parentheses; Schaalma et al., 1993a).

Experience with intercourse

Attitude (-6/+6)
Beliefs (-90/+42)
'Vulnerability (+2/+10)
Self-efficacy (-45/+45)
Injunctive social norm (-15/+15)
Descriptive social norm (-2/+2)
Intention (-15/+15)

none
(n=792)

little
(n=75)

much
(n=137)

2.4a
-0.9a
6.2
9.5a
3 . la
0.7
7.0a

1. Sab
-7.6b
6.2
12.6b
3.8a
0.5
5.7a

1.1b
-9.7b
5.9
13.7b
1.0b
0.4
2.4b

Means in rows with unequal subsripts differ (p<0.005)

68

Diffusior

Mario A Orlandi
Cassie Landers
Raymond Weston
Nancy Haley

Chapter 13

Diflusion of
Health Promotion Innovations

During the past three decades, the way in which we think about
health and disease has changed dramatically.* This change is a
result of the realization that individuals can significantly influence
their health and longevity and that they can prevent the onset of
chronic disease by changing their life-styles. The translation of this
recent epidemiological understanding into the widespread reduc
tion of avoidable morbidity and mortality through behavior change
has rapidly become a common theme for the public health com
munity (Green, 1979).
However, many individuals and in fact large segments of
society continue to engage in behaviors that are known to lead to
premature disability and death (Yankauer, 1988). The gap between
what health professionals believe people should do and what the
general population actually does has become one of the principal
challenges of public health today (Baquet and Ringen, 1987).
In response to this challenge, public health researchers have
begun to study systematically the barriers to bridging this gap in an
attempt to identify more effective and more cost-efficient interven
tion strategies. One important perspective that has only recently
been explored within the context of health promotion research for

*Ihis work was supported in part by a grant from the National Heart,
Lung and Blood Institute (HL-40688).

288

Health Promotion Innovations

289

chronic disease prevention and management is the area of diffusion
theory (Winett, 1986; Rogers, 1983). The process of translating new
health-related research findings or effective interventions into wide
spread behavior change for the good of society is a classic example
of the general process defined as the diffusion of innovations.
This chapter discusses various aspects of diffusion theory
that have direct applicability to the problem of bridging the health
promotion gap. In doing so, the chapter focuses on three key areas:
First, it reviews the Amcepi of a generic diffusion system and notes

some limitations of the classic diffusion model. Second, the chapter
describes an alternative research framework that enhances standard
approaches to both innovation development and diffusion plan
ning by incorporating methods for increasing target group partici
pation. Third, the chapter provides an example of this research
framework in the form of a community-based health promotion
study that utilizes this approach during all phases of program plan
ning and implementation. The chapter concludes with an analysis
of questions that are left unanswered and directions for future
research.
Contemporary Perspectives on Classical Diffusion Theory

Diffusion is defined as the process by which an innovation is comm uni rated through < ertain channels over time among members of a
social system (Rogers, 1983). An innovation is an idea, practice,
service, or other object that is perceived as new by an individual or
other unit of adoption. Classical diffusion theory developed as an
attempt to explain this communication process in a rigorous and
scientific way that would have predictive validity from one innova
tion situation to another (Rogers, 1983, p. 333). The original model
was also an attempt to determine the most consistently effective way
to apply solutions that are developed in test settings to problems in
real-world settings.
The study of diffusion of innovations has its roots in rural
sociology, and early applications included investigations of how
new agricultural technologies spread (or failed to spread) among
farmers. Subsequent work applied diffusion theory to a wide variety
of practices and technologies, including family planning and the

0
G
1

In

290

Health Behavior ar*1 Health Education

Diffusio
use of medical screening tests and new pharmaceutical products.
Diffusion research spans many countries, cultures, and issues (Rog
ers, 1983). In three separate books over nearly three decades, Everett
Rogers has synthesized thousands of diffusion studies and advanced
the understanding of diffusion theory and its utility in many set
tings (Rogers, 1962, 1983; Rogers and Shoemaker, 1971).
A basic assumption underlying the early work in this area
was that diffusion patterns and adoption rates of particular innova
tions are determined primarily by the scientific attributes of the
innovation and the uniqu£_chaxacteristics of the adopter. Following
this line of reasoning therefore led to the assumption that a thor
ough analysis of innovations that had been adopted and of the
organizations or individuals that had adopted them would result in
formulas for successful diffusion that could be applied to other
innovations in other settings.

Features of Successful Diffusion Efforts. Though such variables
have been redefined and modified over time, several of them have
been consistently identified as attributes of successful diffusion ef
forts (Kolbe and Iverson. 1981). These include the following:

Compatibzltty. When innovations are consistent with the
economic, sociocultural, and philosophical value system
of the adopter, adoption is more likely to take place.
Flexibility, Innovations that can be unbundled and used as
separate components will be applicable in a wider variety
of user settings.
If for any reason, the adopting individual or
organization wants to revert to its previous practices, it is
desirable that ani innovation be capable of termination,
Innovations that ;are not are less likely to be adopted.
Relative advantage. If an innovation appears to be beneficial
when compared to current and previous methods, adoplion is more likely.
Com^xi^uComplex innovations are more difficult to com
municate and to understand and are therefore less likely to
be adopted.
Cost-efficiency. For an innovation to be considered desirable,

Health Promotion Innovations

291

its perceived benefits, both tangible and intangible, must
outweigh its perceived costs.
Risk. The degree of uncertainty introduced by an innovation
helps determine its potential for adoption. Innovations 1
that involve higher risk are less likely to be adopted.
This classical approach also established specific roles for dif
ferent interest groups that interact as part of the overall diffusion
system. Innovations were seen as originating from a resourcejystem
that has the knowledge and expertise required to create the new
concept. 1 he innovation was viewed as a uniform, intact entity that
moves from the resource system to the adopting individual and/or
organization, which were described collectively as the user system.
7 hough the classical diffusion model has contributed greatly
to our understanding of this important research area, it has been
challenged in the recent past in a number of ways (Rogers, 1983;
Basch, Eveland, and Portnoy, 1986). First, the characterization of
the innovation as an intact package directs attention toward the user
system and the adoption decision and away from the concept of
innovation refinement as a.means of improving thej‘fit" betweeen
innovation and user. Second, this orientation does not provide an
adequate means of evaluating the potential contribution of efforts Zon the part of the resource system or the user systemlo Influence the
diffusion process. In this sense, as a rule, the process is viewed as
static rather than dynamic. Third, the classical model fails to recognize the fact that the adoption decision is_pnly one step in a multistep process that ranges from the first phases of innovation
development to a point beyond adoption at which the innovation
either succeeds or fails in achieving a lasting and meaningful im
pact. I his point is critical, for example, when the innovation under
consideration is a health promotion intervention. As the next sec
tion of this chapter indicates, a significant impact from a public
health perspective requires maintenance of intervention effects that
extend far beyond the adoption decision.

Potential System Failure Points. With respect to the multistep pro
cess, modern conceptualizations of the diffusion process typically
and more realistically view each step as a potential failure point—a

292

Health Behavior r ’ Health Education

critical barrier that must be overcome for the overall system to
achieve a lasting and meaningful impact. These potential system
failure points include the following:

Innovation failure. The system can fail if the innovation does
bring about its intended effect. For example, this
might occur if an mnovation, though highly touted, had
been poorly designed, inadequately evaluated, or dishon
estly represented.
Communication failure. An innovation can be genuinely ef
ficacious and have the potential to achieve its intended
effect yet fail to do so because it was communicated inef
fectively^ Failure at this stage normally means that the
user subsystem was either unaware of theinnovation or
was improperly informed as to its availability or
applicability.
Adoption failure. Though efficacious and properly com
municated, an innovation may not be adopted because of a
host of factors ranging from differing value and belief
systems to a lack of necessary resources.
Implementation failure. Despite being successfully adopted,
an innovation may not be implemented properly or even
implemented at all. I his frequently occurs when specific
program components (such as instructor training) that are
considered instrumental to the program’s efficacy are
omitted or drastically abbreviated. I his is more likely to
occur when programs are adopted at the organizational
level (for example, the corporation or school level) and
then implemented by the organization among its
members.
Maintenance failure. Even though an efficacious program
may be successfully communicated, adopted, and initially
implemented, it can lose its momentum and dissipate rap
idly over time. From a health promotion perspective, pro
gram maintenance over time is critical.
The Innovation-Development Process. As this overview indicates,
diffusion theory begins conceptually with an innovation that has

Diffusio *4 Health Promotion Innovations

293

the potential for communication and adoption. The relationship
between diffusion theory and health promotion innovation
development can best be understood as a specific application of the
innovation-development process. This process includes all the deci
sions and the activities and their impacts that occur from the early
stage of an idea through its development and its production, diffu
sion, adoption, and consequences (Rogers, 1983, p. 135). A six-stage
innovation-developmentj>rnrpss includes these main steps: (1) rec
ognition of a problem or need; (2) basic and applied research; (3)
development to put a new idea into a form that is expected to meet
the needs of an audience of potential adopters; (4) commercializa
tion that involves production, marketing, and distribution of the
innovation; (5) diffusion and adoption; and (6) consequences (Rog
ers, 1983).
Federally sponsored health promotion innovation research
has been described according to a five-phase model that parallels the
general innovation-development process and includes basic re
search, applied research and development, clinical investigation,
clinical trials, and demonstration and education research (U.S. Department of Health and Human Services, 1987). However, despite
the value that has been placed upon this paradigm, there is little
evidence that innovations that result from this process are necessar
ily more successfully diffused than those that do not (Kolbe and
Iverson, 1981; Patton, 1978). A number of factors contribute to this
inconsistency, including the limited involvement of user systems in
developing innovations and the gaps in translating knowledge ac
quired in controlled research studies into real-world settings. A
further limitation is that research usually focuses on short-term
intervention effec ts and,fails to consider longer-term issues such as
program maintenance that are critical to improvements in public
health.

Innovation Development and Diffusion:
A Conceptual Integration
Health promotion innovation development is a process that begins
with basic research and hypothesis testing and leads ultimately to
demonstrations in real-world settings. The heart of diffusion theory

294

Health Behavior and Health Education
Diffusi

□f Health Promotion Innovations

295

begins, essentially, where innovation development leaves off in an

attempt to characterize the success of an innovation as it moves out
of research and development settings and into real-world settings. If
this system functioned flawlessly, there would be many more health
promotion innovations in operation in settings where they could
potentially have a significant impact (Yankauer, 1988).
As noted earlier, a significant number of barriers have the
potential, if left unaddressed, to undermine the objectives of either
the innovation-development or the innovation-diffusion process.
I he fact that many of these barriers frequently are left unaddressed
and that the gap frequently remains is evidenced by the number of
health promotion innovations that remain ‘‘on the shelf” after con
siderable development effort (Iverson and Kolbe, 1983). Though
diffusion and applicationi are the goals of these efforts, they typically are not the outcomes.
In some respects, the problem can be viewed as a gap that is
frequently left unfilled between the point where innovation
development ends and diffusion begins. Some of the factors that

contribute to innovation efficacy and diffusion success are very sim
ilar, and there are strategies that can be used to address these factors
simultaneously. The purpose of doing so is to attempt to bridge the
SaP that often remains when innovation-development barriers and
diffusion barriers are considered separately, as though they were
aspects of unrelated problems.
One stiategy that attempts to bridge this gap is the linkage
<q)proach22Tn,!TY^^
and diffusion planning. The
key to this approach lies in its reliance on increased target group
participation in all aspects of the process.

Figure 13.1. Overview of the Linkage Approach to Innovation Diffusion.

Active
Diffusion
(2)

Resource
System
(1)

Linkage
System
(3)

Implementation
(4)

User
System
(5) '

1. The resource system consists of researchers, developers, trainers,
consultants, services, products, and materials.
2. The diffusion process is the range of activities carried out specifically
to result in the spread of an innovation to specific target groups.
3. The linkage system consists of representatives of the resource system,
representatives of the user system, change agents, and strategic
planning activities.

A methodology for bridging the health promotion diffusion
gap that enhances both the innovation-development process and the
diffusion planning process is lhejinkage approach. This perspec
tive was first described by Havelrck (1971) ami later expanded by
Kolbe and Iverson (1981) and Orlandi (1986a, 1987). Il involves the
integration of three separate but interactive systems into a single

4. The implementation process may be carried out either by members
of the user system who have received training or by members of the
resource system. The important point is that the implementation process
and the innovation itself have been developed through collaboration,
thus increasing the likelihood that efficacious approaches will be used
in a culturally sensitive manner whenever possible.

general systems model (see Figure 13.1).
In addition to the resource and user systems, in which inno

5. The user system consists of the individuals, organizations, agencies,
groups, and networks.

vations originate and are ultimately adopted (oi not adopted), a
linkage system that represents the cooperative exchanges and inter-

296

Health Behavior

1 Health Education

actions required to collaboratively develop user-relevant innovation
and diffusion strategies is defined. The individuals who interact
within the linkage subsystem include representatives of the user and
resource subsystems plus change agents, who facilitate the collabo
ration. The role of change agent does not have to be filled by an
independent third party; members of the user or resource subsystems
can also operate in this facilitative capacity.
The most critical aspect of this approach is the perspective
that defines the information exchange that takes place within the
linkage subsystem. This perspective incorporates elements of com
munity organization (see Chapter Twelve) and theories of organiza
tional change (see Chapter Fourteen); however, it is most closely
aligned with social marketing (Bloom and Novelli, 1981), an area
that is described in depth in Chapter Fifteen of this book. Several
characteristics of the_socia!jii3rKe^
are critical to the
area of innovation diffusion in general and to the linkage approach
to innovation-development and diffusion planning in particular.
According to this perspective, the role of the resource system
is to collaborate with the user system in the innovation planning,
process by helping the user system determine its needs, expectations,
and limitations. Optimally effective innovation messages and
strategies must take into consideration a variety of socioculturally
relevant communication factors. Therefore, data must be collected
to help define these communication characteristics in ways that are
likely to enhance the efficacy of the intervention message.
The techniques of social marketing research, which include a
variety of methods for gathering relevant quantitative and qualita
tive data, are designed specifically to optimize the effectiveness of
the innovation-development and diffusion planning processes by
addressing issues such as user group preferences, perceived needs,
and limitations. 1 he two key concepts directing these formative
research activities are segmentation of a general population into
relevant subgroups and tailoring an innovation to the particular
characteristics of the targeted segments (Orlandi, 1986b).
The preceding discussion describes a promising line of rea
soning for approaching the development of health promotion inno
vations and suggests methods for designing innovation-develop
ment research studies. Three ideas are central. First, the multiple

Diffusi

af Health Promotion Innovations

297

objectives of modern diffusion theory are kept in mind as are the
various steps at which such a process can fail. Second, the five-phase
innovation-development research model discussed earlier (U.S. De
partment of Health and Human Services, 1987) is employed, with
careful attention to the objectives of each phase. Third, the known
limitations and gaps of these approaches are addressed and, one
hopes, minimized through the use of a linkage approach and social
marketing research methods to enhance the quality and quantity of
target group (user system) participation in the program develop
ment and research process. The next section provides one example
of how this theoretical framework is being carried out.
The Mount Vernon CARES Project

Ihe American Health Foundation is involved in the design and
implementation of innovative community-based cholesterol screen
ing, education, and referral strategies. The overall goal of this effort
is to design, implement, and evaluate strategies to enhance the effec
tiveness of a community-based cholesterol screening system and to
elicit participation of members of the Black American population
who have traditionally been unresponsive to such efforts. The inter
vention system includes components to (1) enhance cholesterol
awareness, (2) increase participation in cholesterol screening activi
ties, and (3) motivate those identified as at risk to comply with
referral for further treatment.
Elevated Blood Cholesterol and Health Promotion Innovation.
Elevated blood cholesterol is a major risk factor for coronary heart
disease and a significant public health problem, affecting as many
as 50 percent of all adults in the United States (“Report of the
National Cholesterol Educatioi Program Expert Panel,” 1988).
Control of elevated cholesterol io reduce the risk of heart disease
involves detection of high-risk gr nips, diagnosis, and effective treat
ment. The primary treatment approach for high blood cholesterol
levels is dietary change. The recent promulgation of guidelines for
detecting and lowering high cholesterol has spurred important
community and patient health education efforts to improve aware-

298

Health Behavior a^a Health Education

Diffusi*
ness, detection, and adherence to dietary guidelines to reduce ele
vated cholesterol levels (Ernst and Cleeman, 1988).

Both the public’s and health professionals’ awareness and
concern about the problem of elevated cholesterol are rapidly gain

Figure 13.2. Mount Vernon CARES: Overview of Intervention
Development and Implementation.
Year 1

ing momentum (Schucker and others, 1987a, 1987b). Information
about cholesterol management is now flooding all forms of media.
However, gaps in knowledge, attitudes, and practices of health care
providers and at-risk individuals present major challenges for
health care and health education (Glanz, 1988). The set of health

Intervention Strategy Development
• Cholesterol screening
• Nutrition education
• Physician education

innovations and to achieve its successful adoption, diffusion, and
maintenance in defined communities. The Mount Vernon CARES
(Cholesterol Awareness, Risk Education, and Screening) Project is
an effort to accomplish these goals effectively.

Year 2

Overview of Project Components. The intervention community is
Mount Vernon, a biracial community in Westchester County that is
thirteen miles north of New York City. The project is a collabora
tive effort initiated by the American Health Foundation (AHF) and
involving the health, cultural, civic, industrial, and religious orga

Community Education and Participant Recruitment
• Materials dcsign/dcvelopment
• Disscmination-formal/informal channels

Community Intervention
• Information packet
• Cholesterol screening
• On-site nutrition counseling
• Physician referral

nizations serving the Mount Vernon community. The broad pro
gram goal is to implement a cholesterol education, screening, and
referral program for Mount Vernon residents aged eighteen and
older over a three-year period. As indicated in Figure 13.2, several
components of the Mount Vernon CARES Project are being de
signed, implemented, and evaluated:

population are being developed. In addition, innovative
recruitment strategies to elicit community participation
are being devised.

Community Assessment and Analysis
• Market segmentation analysis
• Key informant interviews
• Community survey
• Physician survey

t

promotion innovations that is most effective and can be refined and
diffused is in an early stage. The challenge is to develop this set of

Community assessment and a?ialysis. A sample of resident
and community leaders are being interviewed at baseline
and at years two and three of the project to determine
changes in community knowledge, attitudes, and practices
regarding cholesterol as a result of the intervention.
Community education and recruitment. Educational mate
rials designed specifically to meet the needs of the target

>f Health Promotion Innovations

Follow-Up Intervention for At-Risk Participants
• Physician referral and compliance
• Nutrition workshops

Year 3

t
Cholesterol Rescrcening for At-Risk Participants
• Nutrition education

f
Outcome Evaluation
• Community survey
• Physician survey
• Participants survey

299

300

Health Behavior

d Health Education

Physician education. A physician education program focus^ig on the management of patients with elevated choles
terol levels will be conducted in collaboration with
community health institutions.
Cholesterol screening^ A series of cholesterol screenings will
be held in collaboration with community organizations at
a variety of locations throughout the city. An information
packet tailored to the needs of the target population will
be distributed, and on-site nutrition counseling will be
available. In addition, participants found to be at risk will
be advised to seek follow-up.
Nutrition workshops and rescreening activities. A series of
nutrition workshops will be offered to provide in-depth
education and skills for modification of dietary behavior.
For those individuals with elevated cholesterol levels, a
rescreening will be available in year three of the project.
In the design and implementation of these components, var
ious social marketing research techniques are being employed in an
attempt to anticipate specific barriers to the implementation of the
proposed screening and referral program. These barriers can be dassified into three general categories: (1) harriers to participation, (2)
barriers to effective screening, and (3) barriers to compliance with
physical referral and rescreening. The following section describes
the application ol selected social marketing techniques in an at
tempt to gain insights into the community residents and pertinent
organizations and to understand the nature of the barriers to partici
pation, screening, and follow-up in the Mount Vernon community.
Community Assessment and Analysis. As indicated in Figure 13.2,
community assessment and analysis was the first step in the inter
vention development process. One objective was to obtain informa
tion about the social, cultural, and political dimensions of the
target group of Black Americans within the general community. A
second objective of the analysis was to assess the strengths and po
tential weaknesses of the existing health service delivery system.
This section describes the application of community assessment
activities and presents highlights of the analysis of existing data

Diffus;

of Health Promotion Innovations

301

sources, semistructured interviews with key informants, and tele
phone surveys of community residents and physicians.
Sociodemographic indicators were obtained through the
analysis of census and other archival data sources. From this infor
mation, we learned that Black Americans comprise 48.7 percent of
the 67,000 residents in Mount Vernon and that this proportion ap
pears to be increasing. The median age is thirty-five years, and
much of the working population is made up of skilled and semi
skilled blue-collar workers.
Analysis of selected characteristics along racial lines revealed
important differences in the population. White residents of Mount
Vernon tend to have higher incomes, less unemployment, and more
formal education. Both blacks and whites have relatively stable peri
ods of residence in the community.
Analysis of the twenty-one census tracts comprising Mount
Vernon helped to identify three distinct groups. Group 1 is predom
inantly black (72.8 percent), is less often high school educated (50.9
percent), and has a significant proportion (23.9 percent) of femalebeaded households. Group 2 is a racially mixed population, with
somewhat higher levels of high school education (66.8 percent) and
fewer female-headed households (15.7 percent) than Group 1.
Group 3 is of higher income, predominantly white, has a higher
educational level, and tends to use health and recreation facilities
outside of Mount Vernon proper. The segmentation that was re
vealed by this census tract analysis was an important basis for tailor
ing specific intervention components to specific population
subgroups.
A second type of data collection activity involved a series of
semistructured interviews with community representatives of
health, civic, industrial, and religious organizations. The inter
views, conducted by trained AHF personnel, focused on three major
themes: organizational objectives; obstacles encountered in accom
plishing these objectives; and social, economic, and cultural
strengths and weaknesses of the community. A secondary objective
of these interviews was to gain insight into the feasibility of the
proposed cholesterol intervention and the potential obstacles that
might be encountered. In addition to serving as a means for data
collection, the interviews identified potential collaborators and pro

302

Health Behavior ar-* Health Education

vided an initial entry point into the
power structure in the
community.
The third set of data collection activities during the interven■on plannmg phase invo]ved
of a
pie of community residents as well as physicians practicing in
Mmmt V™. The strateg.es for each of these surve^ will bA.s-

attnudls r??0 "hr31"

°n the Pminen‘ knowledge,

a ti udes, behefs, and practices of Mount Vernon residents, we con
ducted a telephone survey with a random sample of 550 residents
om

roups 1 and 2 (the two community segments with most of the

b ac pop !

The survey wi]1 be

‘T' C°mniUn^ and to

impact. A

year! of the
W11' fol'OWed throughout the three
these in^vM T'1
e'mine lmPaCt °f ‘he “ention on
mese individuals over time.
The survey included thirty-five closed-ended questions and
bTckXound nf'ninUteS tO C°mPle,e- QUeSti°nS addressed Pe«°"al
tion t
Ormall°n and knowledge of cholesterol and its rela
tionship o card.ovascular disease. The survey also asked about diee y practices known to affect cholesterol levels as well as exercise

t’o hZ T 7' 'r1 °ther life’Sty'e faCtOrS' This surveV Pr«vided

both baseline data for the evaluation and important insights for
development of educational messages.
In addition to the community survey, a physician telephone

eZiine d

a‘t,tUdeS’

°f Ph^-

rega ding the management and treatment of individuals with ele
vated cholesterol levels. The survey also provided an initial entry
point into the health care system and an opportunity to introduce
the program to the medical community. Physicians surveyed in
cluded internists, cardiologists, and family practitioners affiliated
with enher of the two health care facilities serving Mount Vernon
Before the telephone survey, we sent an introductory letter to
physicians about the community cholesterol program as well as the

tlrm^n

lealth Promotion Innovations

303

to the design of effective referral strategies. Therefore, we identified
the need to pursue alternative strategies to elicit the support and
commitment of physicians serving the community. These strategies
included providing information at grand rounds, distributing in
formation flyers, and eliciting the support of a key physician from
each institution to act as a project facilitator. In addition, we con
ducted interviews with physician; in the health care setting.
I hrough these efforts the physician response rate was increased to
60 percent. Additional attempts to further increase this participalion are in progress.

J

and three of the project to help determine the ability of the interven-

X TlOO bT

Diffusion

P'le Ze!f°rtS’ thC lnitia' SUrVey reSP°"Se rate was

than 20 percent. Whtle physician resistance to community-based

screening programs is common, physicians’ cooperation is critical

Intervention Strategy Development. This section describes the se
quence of activities involved in developing strategies for the choles
terol screening, nutrition education, and physician education
components of the intervention.
Because we recognized the need to involve the community in
the initial planning phases, the Community Advisory Board was
established. The board consists of t ight community leaders and,
among other things, provides continual insights into the sociologi
cal, cultural, and political dimensions of the community. The first
responsibility of the committee was to create a project theme, name,
and logo. Following this activity, the board has played a pivotal
role m identifying community organizations capable of successfully
carrying out the screening events.
We recognized the need to develop a range of complementary
strategies in order to reach the black population, which has been
unresponsive to traditional recruitment strategies (Wynder, Harris,
and Haley, 1989; Wynder, Field, and Haley, 1986). Through an
elaborate negotiation process with representatives from prospective
interested institutions, fourteen participating community institu
tions were identified. The cholesterol screening sites included
health institutions, work sites, community service organizations,
< hniches, and low-income housing projects.
The selection of these, sites was guided by the census tract
analysts performed during the community assessment phase of the
|>roject. The segment of the population least likely to participate in
community-based health promotion events resides in the area de
fined by Group 1. In an effort to attract the participation of this

304

Health Behavior

4 Health Education

segment, we selected five screening sites including the Neighbor
hood Health Center, a YMCA, a large Baptist church, and two lowincome housing projects. Nine screening sites are located within the
geographical boundaries comprising Group 2. These include the
Mount Vernon Hospital, two community service organizations, city
hall, two work sites, and three churches.
The nutrition education component has been developed
partly on the basis of data collected during the community assess
ment phase, which underscored the need for community-based nu
trition resources. The two-part nutrition component includes on
site nutrition counseling at screening locations and a series of
follow-up workshops on nutrition for those individuals identified
with elevated cholesterol levels. I he AHF will complete initial de
sign of the follow-up workshops, which will be implemented by
nutritionists horn five community service organizations within
Mount Vernon. I his approach ultimately will strengthen the com
munity’s nutrition education resources and will also foster commit
ment to the program from within the community.
The physician education component consists of a two-part
lecture program that is being integrated into the continuing medi
cal education program of the community’s two health care institu
tions. I’he lectures address barriers identified by the physician
survey and provide a clear, concise, and action-oriented approach to
patient management. I hey are delivered by a cardiologist with ex
pertise in the management of patients with elevated cholesterol.
I he lecture content and timing parallels the community program:
I he first lecture foc used on diagnosis and management of elevated
cholesterol and was delivered several months prior to the screening
program. A second lecture addressing dietary management imme
diately follows implementation of the screening program.
Physicians have noted the need for follow-up information to
help monitor patient compliance. Thus, in addition to the lec ture
series, physicians will receive “booster materials’’ during the inter
vention phase oi the* program. A physic ian survey during year three*
of the projec t will determine the impact of the program on physi
cians attitudes and practices related to cholesterol management.

Diffuj

of Health Promotion Innovations

305

Community Education and Participant Recruitment. The se
quence of tasks involved in the design and development of interven
tion materials and communication through formal and informal
dissemination channels is depicted in Figure 13.3.
The first step was to review available cholesterol education
materials. A review of existing printed materials revealed a serious
lack of information tailored specifically to the needs of Black Amer
ican populations (U.S. Department of Health and Human Services,
1989). It further showed that available materials failed to recognize
implementation barriers unique to this minority group.
With these barriers in mind, we developed a set of comple
mentary educational materials tailored to the needs of Mount Ver
non s black population. This process began with the identification
of a series of educ tional “themes’’ or messages that comprised the
basic educational objectives of the intervention. Once identified,
these messages would be continually reinforced and disseminated
thiough a variety of formal and informal message channels. The
development of the message design strategy attended to factors such
as content, design, persuasion, and memorability. On the basis of
commonly asked cholesterol-related questions, a message campaign
using a question-and-answer format was created. Focus groups were
conducted to test the effectiveness of these messages both with
members of the target population and with technical experts in
nutrition and health promotion. Through these focus groups, the
content, format, and struc ture* of the messages were refined.
In addition to printed materials, we designed a video to in
crease awareness of cholesterol as a risk factor for members of the
black population. The video was filmed within Mount Vernon; its
content focuses on the reaction of a young child to the death of her
father from cardiovascular disease. Both the complete video and
one-minute abbreviated versions will contribute to the recruitment
and education of the particularly hard to reach segments of the
blac k community.
In order to overcome the barriers to participation common to
members of the target population, identification and selection of
effective information dissemination strategies was important. A
variety of complementary dissemination strategies utilizing both

306

Health Behavior anc’

?alth Education

Figure 13.3. Mount Vernon CARES: Community Education and
Participant Recruitment.
Identify Existing Resource Materials

|

Design and Develop Educational/Recruitment Materials
• Informational pamphlets
• Flyers
• Posters
• Video
• Community calendar

Diffusion

lealth Promotion Innovations

307

formal and informal communication channels was developed ac
cording to the subpopulations that had been identified through
census tract analysis. Factors related to message selection were
matched with a particular dissemination channel in order to reach a
specific subgroup of the target audience. Through this approach

intervention messages have the best potential to penetrate all segmerits of the community.
1 he formal dissemination channels comprising the educalion and recruitment component for the program include public

service announcements, press releases, newspaper advertisements,
direct mail inserts, community bulletin announcements, cable tele
vision announcements, bus shelter posters, and locally distributed
posters, pamphlets, and flyers.
In addition to these distribution channels, a variety of infor
mal strategies are being implemented. Promotion of a health inno

Revicw/Rcvise Materials

Develop Information Dissemination Strategy

vation through word-of-mouth contacts provides opportunities for
feedback that is not possible through the printed word. Given the
inability of media campaigns alone to motivate desired behavior
< hanges, a series of informal promotional events has been designed

to complement the formal distribution channels. The informal
channels include announcements at community, social, and recrea
tional events; church service announcements and discussions; video
presentations and group discussion; presentations at community
meetings; and a phone-a-thon.

Formal Channels
• Public service
announcements
• Press rcleasc/ncwspapcr
advertisements
• Cable television
• Local distribution of posters,
pamphlets, flyers

Informal Channels
• Community announcements
at social/rccreational events
• Community meeting
announcements
• Church service
announcements
• Kickoff event
• Video presentation
• KISS-FM van

Implement Education/Recruitment Strategy

The screening implementation phase will begin with a kick
oil press event, featuring the mayor of Mount Vernon as the first
Mount Vernon resident to receive a cholesterol screening test. One
additional recruitment and communication technique utilizes the

participation of a very popular radio station in the community The
station's promotional van will be located at a major screening site
and will make live radio announcements throughout the screening
event.
&
The education and recruitment activities described in this
section will be implemented during the six weeks prior to initiation
of the screening activities. Intensified recruitment will take place
within the last few days immediately prior to the screening and will
continue throughout the screening period. The program is expected

308

Health Behavior a ’ Health Education

to elicit the participation of at least 10,000 adult Mount Vernon
residents.
Cholesterol Screening and Follow-Up. When participants enter the
screening site, they will be given a participant information packet.
The packet includes the pamphlet with the project’s key educa
tional messages, including “Cholesterol: Know the Facts,” “Watch
What You Eat, and “Get the Total Picture.” Participants will also
receive a cookbook that was designed to address the dietary practices
of the target audience and includes multiethnic low-fat, lowcholesterol recipes; information on understanding nutrition labels;
tips for meal preparation; and tips for choosing low-cholesterol
meals in restaurants. In addition to specially developed materials,
the packet includes the AHF’s “Health Passport,” an AHF choles
terol information pamphlet, a dietary information brochure from
the Westchester County Department of Health, a survey form, and a
consent form.
At each of the screening sites, volunteers will work with su
pervision from AHF cholesterol screening personnel to guide par
ticipants through the screening process. Participants will complete
a consent form and then proceed to the blood sampling section.
Next, their blood will be drawn by trained and certified technicians
using a finger-stick method. Blood samples will be analyzed on-site
with Kodak Ektachem DT60 analyzers, and participants will receive
the results of their cholesterol screening within approximately
thirty minutes. During this waiting period, participants will be
asked to complete a survey (juestionnaire.
lhe information requested on the self-administered survey
includes background data on ethnicity, age, socioeconomic level,
marital status, and educational level. Additional questions address
prior knowledge of the respondent’s cholesterol level, previous ill
nesses, dietary practices, and life-style factors, including physical
activity and smoking. The information obtained through this sur
vey will provide insight regarding factors associated with the distri
bution of cholesterol levels within and between population sub
groups.
The same survey will be readministered to all participants
with elevated cholesterol levels who participate* in a cholesterol re

Diffusit

f Health Promotion Innovations

309

screen at a twelve-month follow-up. This follow-up screening activ
ity will allow for comparison of individuals over time to determine
the effectiveness of the physician referral and nutrition education
components in helping to lower cholesterol levels of the at-risk
population. A unique identification code will allow tracking of
participants and matching of survey forms with blood samples.
An additional strategy to obtain accurate and complete con
tact information for participants involves attachment of a “health
lotto’’ form to each survey. The participants will be asked to provide
theii phone numbers and addresses so that winners can be notified;
this will enhance long-term participant tracking for the project
evaluation.
In addition to the self-administered survey, fifteen-minute
face-to-face interviews will be conducted with a random sample of
1,000 Black Americans. The goal of these interviews is to develop a
behavioral prediction model by identifying individual characteris
tics that are often associated with the capacity for self-change. The
interview content and format, based on Prochaska and DiCle
mente’s (1983) model of stages and processes of change, will utilize a
transtheoretical model involving ten processes of change within a
live-stage change model.
Both before their blood samples are drawn and while they are
waiting for the results, participants will have the opportunity to
view a series of cholesterol education videos. When the screening
results are ready, participants with cholesterol levels placing them
at moderate to high risk will be invited to proceed to the nutrition
information area, where they may receive on-site nutrition counsel
ing and the high cholesterol pamphlet designed specifically for this
program. The pamphlet uses a simple question-and-answer format
and provides information on the interpretation of cholesterol scores
as well as recommendations for behavior change.
All patients with moderate to high cholesterol levels will be
referred for additional physician follow-up. Referral messages deliv
ered at the screening will emphasize that screening cholesterol
scores alone should not be used for diagnostic purposes. High-risk
individuals will receive physician referral information for both the
Neighborhood Health Center and the Mount Vernon Hospital. In
addition,
information
----------------- 1 on the time and place of the nutrition follow-

310

Health Behavior

Health Education

up workshops will be available, along with a nutrition telephone
hot-line number to obtain detailed information.
Mount Vernon CARES as an Application of Theory: Prognosis for
Success. Because the Mount Vernon CARES Project is in the early
stage of program implementation, screening participation and im
pact data are not yet available. However, progress toward develop
ing an innovation that will be effectively adopted and diffused
among blacks in Mount Vernon is already evident. The process of
collaboration with community members is marked by the establish
ment of the Community Advisory Board, identification and cooper
ation of feasible screening sites, ihyoTyement of community
members in assessrnenLsurveys, and the increased participation of
physicians in the project survey.
Most importantly, the linkage approach has been put into
action through collaboration of the resource system (the AHF) with
the user system to enhance innovation planning. Social marketing
research methods have been invaluable in refining the AHF’s under
standing of the target population. The careful and continuing use
of the processes that have begun will assure a cholesterol screening
and management program that is compatible, flexible, advanta
geous, cost-efficient, and low risk. The innovation is viewed as a
dynamic and evolving “package” rather than a fixed product to be
accepted or rejected.
The ultimate success of Mount Vernon CARES will also re
quire vigilance in attending to potential system failure points: in
novation failure, communication failure, adoption failure,
implementation failure, and maintenance failure. Success of the
program is further dependent upon the ability of the AHF and
collaborating institutions to negotiate and cooperate carefully.
Within the limits imposed by the research design, the AHF recog
nizes and accommodates the needs of community organizations.
The willingness and interest of the community to participate in the
program stems in part from the perception of community owner
ship generated by this process. Representatives from the various
sites are motivated by the opportunity to be perceived as providers of
a particular set of services, thereby enhancing their own sense of
involvement and personal and organizational efficacy.

Diffusio

Health Promotion Innovations

311

The art of community negotiation is a process that
must
proceed cautiously, building upon and continuously reinforcing
a
foundation of trust and credibility. Only then can an effective
health promotion program be designed and successfully diffused.

Conclusion

One of the factors that will significantly influence worldwide health
promotion efforts in the 1990s and beyond is the diffusion of viable
innovanons from those who have them to those who need them
Without widespread diffusion of health promotion innovations ad
vances in our understanding of chronic disease prevention and
management will realize only a fraction of their potential in preventing avoidable disease and premature death.
The brief theoretical overview presented here suggests that
increasing target group participation is one strategy for improving
e e ficiency of innovation development and the effectiveness of
diffusion efforts. The example from the Mount Vernon CARES
Project supports the feasibility of this approach.
I here are, however, many questions that remain unanswered
and need to be addressed if critical public health goals for the future
are to be met. For example, if a collaborative linkage approach is to
be employed, who shouldjmtiate it? How should the problem of
user groups who donot want to participate in a collaborative ex
change process be anticipated and dealt with? How can quality
SPntmUnd implementation integrity best be maintained afier dif-’
usion has taken place? What factors contribute most to a communi
ty s sense of ownership, and how can these factors be enhanced?
How can a community’s (or an organization’s or an individual’s)
readiness to changejie^ssessed, and how can such information be
utilized by health promotion planners to enhance the diffusion pro
cess How can health promotion providers conduct meaningful and
useful community analyses with limited resources?
The framework and strategies described in this chapter sug
gest an approach for beginning to address some of these issues.
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I

Karen Glanz
Frances Marcus Lewis
Barbara K Rimer
Editors

HEALTH BEHAVIOR
AND
HEALTH EDUCATION

Theory,
Research,
and Practice
\

■a 'J

o

I
Jossey-Bass Publishers
San Francisco

J)

(p

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, Health Behavior an'1 Health Education

ing setting to analyze how the theoretical framework can be used
to guide an intervention to reduce occupational stress among
employees.
In Chapter Ten, Joos and Hickam provide an analysis of the
main theoretical perspectives that contribute to our understanding
of the effects of patient-provider relationships on health behavior
and health outcomes. They analyze four perspectives: cognition and
information processing, interpersonal interaction, conflict between
patients and providers, and social influence. Each of these perspec
tives has its own research tradition and suggests either specific
targets to increase the effectiveness of patient-provider relationships
or methods with which to positively affect patient-provider interac
tion. The applications in this chapter include reviews of observa
tional and intervention studies on patient-provider interaction and
patient outcomes.

Cheryl L. Perry
Tom Baranowski
Guy S. Parcel

Chapter 8

How Individuals, Environments,
and Health Behavior Interact:
Social Learning Theory

Social Learning Theory (SLT) addresses both the psychosocial dy
namics underlying health behavior and the methods of promoting
behavior change. T he cognitive version of Social Learning Theory
emphasizes what people think, that is, their cognitions, and their
effect on behavior. Human behavior is explained in SLT in terms of
a triadic, dynamic, and reciprocal model in which behavior, per
sonal factors (including cognitions), and environmental influences
all interact. An individual’s behavior is uniquely determined by
these factors. Among the crucial personal factors are the individu
al’s capabilities to symbolize the meanings of behavior, to foresee
the outcomes of given behavior patterns, to learn by observing oth
ers, to self-determine or self-regulate behavior, and to reflect and
analyze experience (Bandura, 1986). These ideas have been particu
larly valuable in designing effective health education programs.*
Investigators working with SLT have identified procedures
or techniques that influence the underlying cognitive variables,
thereby increasing the likelihood of behavioral change. Health

*This chapter was funded, in part, by grants from the National Heart,
Lung, and Blood Institute (R18 HL-30625, RO1 HL-25523, UO1 HL39852, RO1 HL-32929, and RO1 HL-35131).
151

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Health Behavior anp Health Education

behavior programs based on SLT thereby use techniques that em
phasize the cognitive mediators of behavior. In this way, the theory
not only explains how people acquire and maintain certain behav
ior patterns but also provides the basis for intervention and learning
strategies. This chapter provides a brief history of the development
of Social Learning Theory, descriptions of key concepts, and two
examples of how the theory has been used to design health educa
tion programs.

Brief History of Social Learning Theory
Social learning theory involves a broad conceptual domain that
incorporates many theoretical ideas and is employed in many areas
of practice. Because an intellectual history of such a broad area
would be impossible to review in just one section of a single chap
ter, publication milestones of SLT in the area of understanding and
changing health behaviors are listed in Table 8.1.
Miller and Dollard (1941) originally introduced Social
Learning Theory to explain imitation of behavior among animals
and humans. The original SLT principles were based on learning
principles and the motivational ideas of Hull (1943). Learning the
ory takes a mechanistic approach to explaining behaviors. The per
son is seen as a “black box,” which emits behaviors called responses
to which reinforcements are applied by other people. Reinforce
ments link the performance of certain responses to particular stim
uli and thereby increase the likelihood of those responses. Hull
attempted to explain why certain kinds of behavior are more likely
to occur than others by considering internal states called drives (not
cognitions). Hull believed that organisms (animals and humans)
acquired drives, physiological processes that often drive behavior.
For example, hunger motivates food search and food consumption.
Hull also maintained that one organism’s responses provide stimuli
for other organisms. Social learning, thereby, is attending to others’
responses when motivated by an acquired drive.
Two streams of health-related research flowed from Miller
and Dollard’s (1941) seminal ideas. Rotter first applied these early
social learning principles to clinical psychology (1954), which in
turn led to his development of the idea of “generalized expectancies

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Table 8.1. Publication Milestones in the Development
of Social Learning Theory.

1941 Miller and Dollard
1954 Rotter
1962 Bandura
1963 Bandura and
1966

Walters
Rotter

1969 Bandura
1973 W. Mischel
1975

Stokols

Zifferblatt

1977

1978

Bandura
Bandura

Farquhar and
others
Bandura

1986

Wallston and
Wallston
Parcel and
Baranowski
Bandura

1987

Rodin

1981

Social Learning and Imitation
Social Learning and Clinical Psychology
Social Learning Through Imitation
Social Learning and Personality
Development
“Generalized Expectations for Internal Ver
sus External Control of Reinforcement,’’
Psychological Monographs
Principles of Behavior Modification
“Toward a Cognitive Social Learning Re
conceptualization of Personality,’’ Psycho
logical Review
“The Reduction of Cardiovascular Risk: An
Application of Social Learning Perspec
tives,” Applying Behavioral Science to Car
diovascular Risk
“Increasing Patient Compliance Through
the Applied Analysis of Behavior,” Preven
tive Medicine
Social Learning Theory
“Self-Efficacy: Toward a Unifying Theory
of Behavioral Change,” Psychological
Review
“Community Education for Cardiovascular
Health,” Lancet
“The Self System in Reciprocal Determi
nism,” American Psychologist
“Locus of Control and Health,” Health Ed
ucation Monographs
“Social Learning Theory and Health Educa
tion,” Health Education
Social Foundations of Thought and Action:
A Social Cognitive Theory
“Personal Control Through the Life
Course,” Implications of the Life-Span Per
spective for Social Psychology

of reinforcement” (1966). Rotter contends that a person learns or is
conditioned operantly on the basis of his or her history of positive
or negative reinforcement. The person also develops a sense of inter
nal or external locus of control. Those with an internal locus of
control are more likely to self-initiate change, whereas those who
are externally controlled are more likely to be influenced by others.

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Health Behavior and ’’ealth Education

Within a learning theory framework, Zifferblatt (1975) applied be
havioral analysis procedures in order to gain an understanding of
compliance behavior. Wallston and Wallston (1978) formulated a
scale for the assessment of the “health” locus of control. They pro
posed that their new measure was more useful in health research
because an individual’s sense of control often varies by domains of
experience and action, such as health experiences. The control liter
ature has evolved to a point at which a need or drive for control has
been postulated with evidence accruing that giving people control
over their lives improves their health outcomes (Rodin, 1987).
While this is an important and interesting area of SLT as applied to
health, we will emphasize the other stream, which has led to more
ideas and techniques for promoting health behavior change.
The other stream of research has progressed far beyond the
behavior theory headwaters, employing cognitive concepts to ex
plain behavioral phenomena. Bandura is the leading figure in this
stream. In 1962, he first published an article on social learning and
imitation. Bandura and Walters (1963) proposed that children learn
by watching other children and do not need to be rewarded directly
in order to learn a new type of behavior. Instead, a child can learn by
observing the behavior of others and the rewards they receive (vicar
ious reinforcement). Prior to this time, learning theory held that
rewards had to be applied directly for learning to occur. In 1969,
Bandura provided a conceptual foundation for behavior modifica
tion that heavily emphasized traditional learning theory. Mischel
(1973) first proposed several cognitive constructs that provided a
cognitive basis for Social Learning Theory. Stokols (1975) applied
the observational learning concept to the area of cardiovascular
disease risk reduction. In 1977, Bandura published his refutation of
the adequacy of traditional learning theory principles for under
standing learning and provided the first theoretical treatment of his
cognitive concept of self-efficacy (Bandura, 1977a). Farquhar and
others (1977) reported the first community-wide intervention for
heart disease prevention based on SLT. In 1978, Bandura proposed
the organizing concept of reciprocal determinism, in which envi
ronment, person, and behavior are continually interacting. In 1981,
Parcel and Baranowski applied the cognitive formulation of SLT to
health education and delineated the stages in the behavior change

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165

process at which each concept was most relevant. In 1986, Bandura
published a comprehensive framework for understanding human
social behavior, using the concepts he helped to develop. In 1986,
Bandura renamed SLT a Social Cognitive Theory. This chapter
reflects this work but continues to use the long-standing label Social
Learning Theory.
Both Mischel and Bandura have introduced a variety of spe
cific constructs in their discussions of the process of human learn
ing. The most pertinent of these constructs to health behavior
change are discussed in this chapter. Cognitive Social Learning
Theory is particularly relevant to health education programs for
three reasons. First, the theory synthesizes previously disparate cog
nitive, emotional, and behavioristic understandings of behavior
change. Second, as demonstrated in this chapter, the constructs and
processes identified by SLT suggest many important avenues for
new behavioral research in health education. Third, the use of SLT
provides an opportunity to apply theoretical models developed in
other areas of psychology to new areas of health behavior.

Social Learning Theory Constructs

Mischel (1973) and Bandura (1977a, 1986) have formulated a
number of SLT constructs that are important in understanding and
intervening in health behavior. Table 8.2 summarizes the constructs
that are described in this section as well as their implications for
potential intervention strategies in health education.
Reciprocal Determinism. An underlying assumption of SLT is that
behavior is dynamic and depends on environmental and personal
constructs that influence each other simultaneously. The continu
ing interaction among a person, the behavior of that person, and the
environment within which the behavior is performed is called recip
rocal determinism. Behavior is not simply the result of the environ
ment and the person, just as the environment is not simply the result
of the person and behavior. Instead, these three components are
constantly interacting. The interaction is such that a change in one
has implications for the others (Bandura, 1978, 1986). According to
SLT, the environment provides the social and physical situation

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Health Behavior and Health Education
Table 8.2. Major Concepts in Social Learning Theory
and Implications for Intervention.
Concept

Definition

Implications

Environment

Factors that are physi
cally external to the
person

Provide opportunities
and social support

Situation

Person’s perception of
the environment

Correct misperceptions
and promote healthful
norms

Behavioral
capability

Knowledge and skill to
perform a given behavior

Promote mastery learn
ing through skills
training

Expectations

Anticipatory outcomes of
a behavior

Model positive outcomes
of healthful behavior

Expectancies

The values that the per
son places on a given
outcome, incentives
Personal regulation of
goal-directed behavior or
performance

Present outcomes of
change that have func
tional meaning

Self-control

Provide opportunities for
self-monitoring and
contracting

Observational
learning

Behavioral acquisition
that occurs by watching
the actions and outcomes
of others’ behavior

Include credible role
models of the targeted
behavior

Reinforcements

Responses to a person’s
behavior that increase or
decrease the likelihood of
reoccurrence

Promote self-initiated re
wards and incentives

Self-efficacy

The person’s confidence
in performing a particu
lar behavior

Approach behavior
change in small steps;
seek specificity about the
change sought

Emotional cop
ing responses

Strategies or tactics that
are used by a person to
deal with emotional
stimuli

Provide training in prob
lem solving and stress
management; include op
portunities to practice
skills in emotionally
arousing situations
Consider multiple
avenues to behavioral
change including envi
ronmental, skill, and per
sonal change

Reciprocal
determinism

The dynamic interaction
of the person, behavior,
and the environment in
which the behavior is
performed

Individual

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167

within which the person must function and thus also provides the
incentives and disincentives (expectancies) for the performance of

behavior. A person has the behavioral capability to act and the
potential for self-control over his or her actions. He or she can also
anticipate certain events and outcomes and can respond to them
(Argyle, Furnham, and Graham, 1981; Magnusson, 1981). Finally,
the behavior, which can be viewed from many levels (Frederiksen,

Martin, and Webster, 1979), reflects the environment and the state of
the person and can affect the enviionment, the person, or both.

Behavior may result from characteristics of a particular per
son or environment, and behavior may be used to change the vari
able (Bern, 1967). If a variable changes, the situation changes, and
the behavior, situation, and perso i are reevaluated. For example, a
man may be so opposed to exercise that his friends come to expect
him to maintain a sedentary life-style. The man has strengthened

this expectation about exercise by avoiding any physical or social
environments in which he might be expected to exercise (for exam
ple, gyms or playing fields). At some point, however, a dramatic
event may occur in this man’s life (for example, the death of a close
family member from a heart attack and exposure to the information
that heart attacks may in part be caused by a sedentary life-style) that
makes him decide to start exercising. The man will now encounter
the expectations of his sedentary friends, who may pressure him not

to exercise. To avoid these negative pressures, he may seek new
friends who value exercise and support his new behavior (reciprocal
effect). This change, in turn, may motivate a sedentary friend to
begin to exercise as well (a reciprocal effect to that friend), and the
friend will then either change the exercise habits of other sedentary
friends, or acquire new friends who are interested in exercise.

This kind of behavior change underscores the importance of
professionals avoiding the simplicity of “single direction of
change’’ thinking. Reciprocal determinism may be used to advan
tage in developing programs that do not focus on behavior in isola
tion but focus instead on changes in the environment and in the
individual as well. The following descriptions of environment and

person constructs should be considered as part of this dynamic
process.

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Health Behavior and *T^alth Education

Environments and Situations. The term environment refers to an
objective notion of all the factors that can affect a person’s behavior
but that are physically external to that person. Examples of the
social environment include family members, friends, and peers at
work or in the classroom. The physical environment might include
the size of a room, the ambient temperature, or the availability of
needed facilities. In SLT, the term situation refers to the cognitive
or mental representation of the environment (including real, dis
torted, or imagined factors) that may affect a person’s behavior. The
situation is a person's perception of the environment, such as place,
time, physical features, activity, participants, and his or her own
role in the situation. This concept of situation corresponds to Lew
in’s (1951) notion of the life space or Bronfenbrenner’s (1977) idea of
microsystem.
The environment can affect behavior without a person’s be
ing aware of it (Moos, 1976). For example, if fresh fruits and vegeta
bles are made available in a child’s environment, for example, at
school, the child will probably learn to include those foods in his or
her diet. The situation, on the other hand, guides and limits think
ing and behavior. For example, the social and physical situation
provides cues about the types of behavior that are acceptable (Rot
ter, 1955). If a child perceives that all of his or her classmates drink
nonfat milk and value its healthfulness, the child may begin to
drink it, too. The situation may also pose certain problems that
require immediate attention, or it may preclude and limit types of
behavior. A person may not be aware of important factors in the
environment, thereby limiting the influence of the environment on
his or her behavior.
The situation also regulates behavior by providing certain
consequences of the behavior. These consequences have positive or
negative values called expectancies, which in turn affect what peo
ple learn. The environment is the source of social supports, such as
friends and family (Baranowski and Nader, 1985a, 1985b; Gottlieb,
1981). From the environmental perspective, social supports in the
environment provide cues for reinforcement and discrimination.
From the situational perspective, the person generates expec tations
and expectancies from people in the environment, and these people

Individuals

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169

may be important resources in approaches to emotional coping and
self-control (Moos, 1976).

Behavioral Capability. The concept of behavioral capability main
tains that if a person is to perform a particular type of behavior, he
or she must know what the behavior is (knowledge of the behavior)
and how to perform the behavior (skill). The concept of behavioral
capability leads to a distinction between learning and performance
because a task can be learned and not performed, but performance
presumes learning. Thus, the purpose of many education programs
is to provide the person with the behavioral capability to perform a
new type of behavior.
The development of behavioral capability is the result of the
individual’s training, intellectual capacity, and learning style. The
behavioral training technique called mastery learning provides cog
nitive knowledge of what is to be performed, practice in performing
those activities, and feedback about successful performance (Block,

1971).
Expectations. Expectations are the anticipatory aspects of behavior
that Bandura (1977a, 1986) calls antecedent determinants of behav
ior. A person learns that certain events are likely to occur in a
particular situation and then expects them to occur when the situa
tion arises again. For behavior that is not performed habitually,
people anticipate many aspects of the situation in which the behav
ior might be performed and develop and test strategies for dealing
with the situation. In this way, people develop expectations about a
situation before they actually encounter it. In most cases, this re
duces their anxiety and increases their skill at being able to handle
the situation. According to SLT, expectations learned from pre
vious experiences in similar situations are referred to as perfor
mance attainments. When they are learned from observing others in
similar situations, this is called vicarious experience. Expectations
may also be learned from hearing about these situations from other
people or social persuasion. Finally, expectations can result from
emotional or physical responses, which are referred to as physio
logical arousal.
An example of how expectations may develop and be

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Health Behavior aiK* Health Education

changed can be seen in the area of adolescent smoking prevention.
Generally, an adolescent “learns” that smoking can be fun, excit
ing, grown-up, or even sexy, from advertising, older peers, or adult
role models. In a health education program, peers can be taught to
direct discussions on the negative social consequences of smoking
and how to handle pressure to smoke from other adolescents. This
approach has been successful in deterring smoking onset (Flay,
1985). In essence, this approach succeeds because the expectations
around future smoking situations for these young adolescents have
been changed.

Expectancies. Expectancies (called incentives by Bandura, 1977a,
1986) are differentiated from expectations in that expectancies are
the values that a person places on a particular outcome. Expectan
cies have magnitude: a quantitative value that is usually represented
on a continuum from 0 to 1 and that can be positive or negative.
Expectancies influence behavior according to the hedonic principle;
that is, if all other things are equal, a person will choose to perform
an activity that maximizes a positive outcome or minimizes a nega
tive outcome. Mischel (1973) believes that expectancies underlie
classical conditioning. For example, in trying to provide weight
reduction skills for overweight adults, one may need to help those
adults replace the positive outcomes of food consumption with neg
ative outcomes. This can be done by stressing the attractiveness or
healthfulness of weight reduction or even more overtly by paying
money for weight loss.
A person’s positive expectancies should be assessed early in a
project that is designed to promote changes in health behavior in
order to identify motivators for that behavior. Many researchers
have observed, for example, that people are more likely to engage in
physical activity to achieve short-term benefits (to become physi
cally attractive, to feel better, or to compete with friends in tennis)
than to achieve long-term gains (for example, to avoid a heart attack
in thirty years). McAlister and others (1980) show that smoking pre
vention programs for adolescents are more successful if they empha
size the immediate negative effects of smoking, such as bad breath or
unattractiveness, rather than the long-term effects, such as morbid
ity and mortality from cancer and heart disease. Thus, an emphasis

Individual

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171

on immediate positive rewards or expectancies may be more likely
to influence the initiation of some desired behaviors than an
emphasis on long-range benefits.
Self-Control and Performance. The term performance refers to the
type of human behavior that focuses on achievement of a goal. One
of the goals of health education is to bring the performance of
health behavior under the control of the individual. Self-control of
behavior enhances the learning and maintenance of that behavior
(Stuart, 1977; Kanfer, 1975, 1976; Bandura, 1986).
The self-regulation models of Kanfer (1975, 1976) and Ban
dura (1986) are perhaps the most sophisticated models of selfcontrol. According to Kanfer, self-control operates through a set of
subfunctions, including self-observations, unambiguous specifica
tion of a target behavior, a criterion for performance, a procedure to
evaluate performance against the criterion, and self-reward. Kanfer
focused primarily on decisions made by people to achieve long-term
self-control and found that the setting of a criterion of performance,
or goal setting, is the most important factor in the achievement of
self-control.
Promotion of self-control requires a focus on a specific type
of behavior. In a weight control program, for example, a target of
“cutting down on sweets” would be too vague to produce observ
able results because a person in the program might become con
fused or could make small changes that conformed to the target but
did not lead to weight loss. Instead of trying to “cut down on
sweets,” therefore, a person might aim to eat eight instead of eleven
cookies a day. A specific goal might also help to promote selfmotivation (Locke, Bryan, and Kendall, 1968) because if a goal is set
too high, a person may become frustrated and give up.

Observational Learning. One reason that SLT considers the envi
ronment to be important is that it provides models for behavior. A
person can learn from other people, not only by receiving reinforce
ments from them but also through observing them and utilizing his
or her symbolic capability. Observational learning occurs when an
observer watches the actions of another person and observes the
reinforcements that the other person receives. This process has also

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Health Behavior an ’ Health Education

been called vicarious reward or vicarious experience (Bandura,
1986).
Observational learning is a more efficient approach than op
erant learning for learning complex behaviors. In the operant ap
proach, a person must perform a given behavior that is
subsequently reinforced. Through a trial-and-error process, the per
son continues to perform behaviors that come progressively closer
to the desired performance. This is an inefficient process. In obser
vational learning, the observer does not need to go through this
time-consuming, trial-and-error process in uncertain circumstan
ces. Instead, the learner discovers rules that account for the behavior
of others by observing the reinforcements they receive for their be
havior. The person can learn what is appropriate by observing the
behaviors, successes, and mistakes of others.
Many types of behavior can be learned through observational
learning (Bandura and Walters, 1963; Bandura, 1972, 1986). This
process accounts for why people in the same family often have
common behavioral patterns. Children observe their parents when
they eat, smoke, drink, and use seat belts and see the various rewards
or penalties the parents receive for these types of behavior. Some
children observe other children smoking at school and notice the
rewards and punishments that the smokers receive. If the smokers
get reinforcements that the observers consider rewarding (accep
tance from peers or a desirable image), the observers are more likely
to perform that behavior in the future.
Reinforcement. Reinforcement is the primary construct in the oper
ant form, as well as in certain other forms, of learning theory. Posi
tive reinforcement, or reward, is a response to a person’s behavior
that increases the likelihood that the behavior will be repeated. In
traditional operant theory, the reinforcement works in an unknown
mechanical way to affect behavior. According to cognitive SET,
however, a person behaves in a certain way to achieve an expec
tancy. Negative reinforcement, or punishment, is not the direct op
posite of positive reinforcement in that it does not always decrease
the likelihood that a certain type of behavior may be performed.
Instead, negative reinforcement may simply reduce the likelihood
that a particular behavior will be performed in those situations in

Individua’

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173

which a person expects to receive negative reinforcement but not in
other situations.
Cognitive SET incorporates three types of reinforcement; di
rect reinforcement (as in operant conditioning), vicarious reinforce
ment (as in observational learning), and self-reinforcement (as in
self-control). These types of reinforcement can be classified further
into external (or extrinsic) and internal (or intrinsic) reinforcement.
External reinforcement is the occurrence of an event or act that is
known to have predictable reinforcement value. Internal reinforce
ment is a person’s own experience, or perception, that an event that
has some value for him or her has occurred.
Internal reinforcement (or internal expectancy) accounts for
why some people behave in a manner that is not reinforced exter
nally or may even be negatively reinforced externally. For example,
a person may choose to return $10 that was given in error as change,
because it was the “right’’ thing to do, even though the $10 would
have provided for the fulfillment of some personal desire, an exter
nal expectancy.
The difference in reward mechanisms is particularly impor
tant in an area that is known as the “overjustification effect.’’ If a
person is given an external reward for a task that is intrinsically
interesting, he or she may find that task less intrinsically interesting
in the future (Lepper and Green, 1978; Bates, 1979). Thus, if a
person who usually enjoys jogging is paid to jog for a week, he or
she may find that jogging is no longer as enjoyable (valuable) as it
was before the payment was provided. Researchers have shown that
any external constraint that is imposed on behavior may reduce the
level of internal motivation (Lepper and Green, 1978). Health edu
cators, psychologists, and others must therefore be careful not to
provide external rewards for all health promotion activities to en
sure that the internal appeal of these activities will be maintained.
They can, however, use external rewards for behaviors that are part
of a behavior change program, for example, maintaining daily diet
records, while they emphasize the intrinsic rewards of the behavior
change itself (Perry and others, 1988).

Self-Efficacy. Bandura and c olleagues (Bandura, 1977b, 1978, 1982,
1986; Bandura and Adams, 1977; Bandura, Adams, and Beyer, 1977)

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Health Behavior and Health Education

have proposed that one aspect of the notion of self, self-efficacy, is
the most important prerequisite for behavior change. Self-efficacy is
the confidence a person feels about performing a particular activity.
Self-efficacy affects how much effort is invested in a given task and
what levels of performance are attained (Ewart, Taylor, Reese, and
Debusk, 1983; DiClemente, 1981). In the process of changing behav
ior, the promotion of self-efficacy becomes a critical concern (Mad
dux and Rogers, 1983; Condiotte and Lichtenstein, 1981; Strecher,
DeVellis, Becker, and Rosenstock, 1986; Rosenstock, Strecher, and
Becker, 1988).
Repetition of the performance of a single task builds a per
son’s self-efficacy, which in turn affects task persistence, initiation,
and endurance, which promote behavior change. Therefore, health
professionals who are training people with diabetes to self-inject
insulin may divide the self-injection process into many small steps,
each of which they can learn through repetition (for example, fill
ing the syringe witji the correct amount of insulin, ensuring that all
items remain sterilized, seeing that no bubbles get into the syringe,
and being sure that the fluid is at the precise marker on the syringe).
Simplifying each step and allowing patients to practice each in
isolation with many repetitions, enables them to build self-efficacy
about performing each step. When patients are self-confident about
each step, they can progressively put the steps together and build
self-efficacy about the entire task.
To make use of self-efficacy in promoting self-control of per
formance, goals should be set in increments that approximate a
given behavior and that are each possible to achieve, thereby allow
ing a person to build self-efficacy about performing the desired
behavior. Both observational and enactive (participatory) learning
techniques can be used in introducing and promoting each se
quence of a targeted behavior (Bandura, 1986).
Managing Emotional Arousal. Bandura (1977a) recognized that ex
cessive emotional arousal inhibits learning and performance and
proposed that certain stimuli give rise to fearful thoughts (stimulus
outcome expectancies). These fearful thoughts produce emotional
arousal and trigger defensive behaviors. As the defensive behaviors

Individuals Environments, and Health Behavior

175

deal effectively with stimuli, the fear, anxiety, hostility, or emo
tional arousal is reduced.
Categories of behavioral management for emotional and
physiological arousal are identified by Moos (1976). One category
includes psychological defenses (denial, repression, and sublima
tion). Another category includes more cognitive techniques, such as
problem restructuring. A third category includes stress management
techniques (progressive relaxation or exercise) that treat the symp
toms of the emotional distress. A fourth category includes methods
for solving problems effectively (clarifying a problem and identify
ing, selecting, and implementing solutions for the causes of the
emotional arousal).
Although many programs employ behavioral management
strategies, their nature varies across individuals and cultures (Diaz
Guerrero, 1979). For example, severely overweight people may find
it difficult to deny or repress their condition. People often react
negatively to overweight people, and these reactions can increase
anxiety about being overweight (Hudson and Williams, 1981). For
some obese people, this anxiety causes overeating (Leon and Roth,
1977; Slochower and Kaplan, 1980; Slochower, Kaplan, and Mann,
1981). Heightened anxiety also makes it difficult to attend to the
health messages coming from health professionals (Ley and Spelman, 1965). Therefore, health educators must learn methods to aid
people in their ability to minimize emotional arousal, before they
can help them to change their behavior, or these educators should
postpone educational efforts until anxiety has subsided.
The following sections provide two concrete examples of the
utilization of SET in health education program design.
The Texas A Su Salud Project

A particularly innovative project based on SET has focused on
smoking cessation and prevention in the community. McAlister and
others (submitted) targeted for change the stresses in life that inhibit
smoking cessation among lower-income Mexican-American fami
lies, thereby enhancing the likelihood of cessation.
As indicated in Table 8.3, many stressful situations either
inhibit the initiation of smoking cessation or enhance the recidi-

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Health Behavior and Health Education

Table 8.3. Major Concepts in Social Learning Theory and Examples
of Their Application in the Texas A Su Salud Project.

Environment

Situation

Behavioral capability

Expec tancies
Observational learning

Reinforcements
Self-efficacy

Reciprocal determinism

Neighborhood-based cueing
Social support for overcoming stressful
problems
Skills to cope with stressful problems (for
example, lack of a job) that interfere with
health behaviors
Skills to stop smoking
The recognition of stressors that interfere
with maintaining nonsmoking
Individual and family counseling for coping
with stressors
The theme of the “six killers’’ in Maverick
County
Mass media role models for stopping smok
ing, for other positive health behaviors,
and for coping with stressors
874 “lay leaders” providing social
reinforcements
A target on perceived ability to cope with
stressors to help maintain smoking
cessation
Promotion of social support and individual
coping skills in dealing with environmen
tal stressors

vism to smoking, after it is stopped. The guiding idea of A Su Salud

is that programs should be targeted at creating a supportive envi

ronment and enhancing a person’s ability to make behavioral
changes.
McAlister and others (submitted) used three components in
their intervention for stopping smoking. The first technique em

ployed a variety of models who demonstrated smoking cessation
activities and examples of behavioral strategies that could be used to
respond to the stressors that inhibit those activities. People from the
community were recruited to demonstrate practices at which they

were proficient, and these were disseminated through newspapers,
radio, and television. By means of this technique, behavioral capa

bility (how to stop smoking) and self-efficacy (confidence in ability
to stop smoking) are modeled by individuals who have been success-

Individup1- Environments, and Health Behavior

177

ful in changing smoking behavior and thereby promote vicarious
learning of cessation skills by other community members.
The media campaign builds community participation into
the communication through the use of “real-life” stories of com
munity members. Although Social Learning Theory concepts have
been employed to actualize modeling in the ideal, the program is
dependent on what members of the community have actually done
to stop smoking or to change other health-related behaviors.
The second program component involved recruiting several
hundred volunteers to establish a community network that is used
to facilitate the dissemination ol information about the role models
in the media and behavioral change. These volunteers, part of the
social environment in the target communities, provide the stimuli
for paying attention to the role models in the media as well as the
social reinforcement for initiated behavior change. The third com
ponent provides individual and family counseling for managing
life events that make it difficult to attend to and set a priority for
( hanging a health behavior. The primary approach to counseling is
referral to the appropriate community agency for mitigating what
ever appears to be the participant’s primary sources of stress.
The staff has underscored the value of engaging in smoking
cessation and the necessary management behaviors by emphasizing
the “six killers of Maverick County” (alcohol and drugs, cigarette
smoking, obesity and diabetes, absence of regular medical check
ups, nonuse of seatbelts, and environmental hazards of the work
place). From work with focus groups, the investigators learned that
residents are aware of the major causes of mortality in their com
munity and are interested in engaging in behaviors that will mit
igate that burden. In their media and other educational activities,
the investigators have linked the targeted behaviors with preventing
the effects of the six killers. Repeated practice of the coping skills,
such as relaxation techniques, has enhanced self-efficacy over these
behaviors. The program has used reciprocal determinism by pro
moting social support and individual skills in dealing with envi
ronmental conditions that increase the likelihood of smoking.
Preliminary results (McAlister and others, submitted) reveal
that the media modeling with social reinforcement and support
from lay volunteers has been more effective than the media model-

178

Health Behavior and Health Education

ing alone in increasing and maintaining the number of nonsmok
ers. There is also some evidence that the individual and family
counseling and referral have been effective in further increasing
cessation among women but not among men.
The intervention strategies are targeted at changing behavior
(smoking) as well as responding to obstacles that inhibit behavior
change. The media messages and role models increase behavioral
capability and influence outcome and efficacy expectations for the
behavior. The community volunteers serve as a means to reinforce
the media messages and to give reinforcement to individuals for
making a behavior change. The volunteer component is a critical
part of the program because it creates a positive expectancy for
behavior change from the social environment. A Su Salud is a good
example of how Social Learning Theory intervention strategies can
address the interaction between individual cognitive factors, behav
ior, and the environment. The use of a community-based approach
(in contrast to most clinic-based programs) that does not rely on
self-monitoring or other intensive therapeutic techniques, appears
promising for enhancing health behaviors.

Minnesota Home Team Study

Social Learning
in me
the development
development oi
of a parent
"■‘a Theory
x nvwiy was
was used
usvu in
involvement program for families of third-graders (ages eight and
nine) in an attempt to change the children’s eating patterns. The
research study has been described in detail elsewhere (Perry and
others, 1988). The design and results are summarized here, with
primary attention being given to the content of the intervention
program. The challenge was to translate the concepts described in
Social Learning Theory into a creative and situation-appropriate
educational package.
The Home Team jprogram
---------- is a correspondence course for
third-graders. Each week for five weeks the students receive a Home
Team packet in the mail. Each packet provides the instructions and
materials for two to three hours of activities to be carried out by each
student and his or her parent(s). Each packet includes a Hearty
Heart and Friends adventure book that tells the story of four charac
ters (Hearty Heart, Dynamite Diet, Salt Sleuth, Flash Fitness) from

Individual' Environments, and Health Behavior

179

Planet Strongheart who travel to earth to teach children about how
to live healthful lives. The packet also includes a variety of games
that provide practice of the basic knowledge and skills that are
presented. Students label foods in their home as “everyday” or
“sometimes,” mix and match foods to rhymes, and look for clue
cards of the Hearty Heart characters and messages around the house.
Each packet includes a simple snack recipe to prepare, a recipe that
the students can subsequently make on their own. The recipes have
team-related names such as “Championship Veggies” and “Fruit,
Fruit, Fruit for the Home Team.” Team Tips, which are refrigera
tor pin-ups that provide additional nutritional information, are
also disseminated weekly. For each activity, points are awarded,
recorded on a scorecard, taken to school, and recorded on a score
board. Teams that complete the Home Team series are eligible for a
grand prize; in the research study this was a family trip to Disneyworld, funded by a local foundation.
Several of the major concepts of SLT guided the develop
ment of the Home Team program. These are summarized in Table
8.4. In particular, the use of an overall incentive for parental partici
pation (the “team” concept with a grand prize), age-appropriate
role models (the Hearty Heart characters), the experiential nature of
the activities (carried out in the home setting), and the option of
additional learning and capability development (through the Team
Tips) were unique components for a school health education pro
gram. These components were necessary, however, from the per
spective of SLT.
The Home Team program was evaluated in a study that
involved thirty-one schools in Minnesota and North Dakota. The
design of the study involved schools assigned randomly to one of
four conditions: the Home Team, an equivalent school-based pro
gram (Hearty Heart), both the Home Team and Hearty Heart, or a
no-program control. At posttest time, students in the Home Team
program, regardless of whether they participated in the Hearty
Heart school program, had significantly changed their fat and com
plex carbohydrate consumption (Perry and others, 1988). However,
students in the school-based Hearty Heart program had acquired
more knowledge. Thus, the application of SLT within the home, a

180

Health Behavior anc*

?alth Education

Tabte,8.4..MajoiiConcepts
Learning Theory and Examples
of Their Application in the
Minnesota- ^ome
Hoi Team Program.
---------------

Environment and
situation
Behavioral capability
Expectations

Expectancies
Self-control

Observational learning

Reinforcements
Reciprocal determinism

Parental involvement in the program’s
activities
Food selection and purchasing changes to
prepare the Home Team recipes
Team Tips, label reading, and food prepara
tion skills activities
Parent-child communication in home-based
activities
The possibility of winning the grand prize
by completing the Home Team program
Goal-setting exercises to increase personal
and family consumption of healthful
foods
Cartoon role models portraying healthful
lives in the Adventures of Hearty Heart
and Friends
Small stickers, Salt Sleuth magnifying
glasses, points to reward completion of
activities
Targeting eating habit changes in a novel
parent-child context through personal
skill development

Individuals,

vironments, and Health Behavior

181

Practitioners who are confronted with real problems often
like the simplicity provided by a single-variable explanation. They
find, however, that many variables must be addressed in a program
to produce behavior change. For example, it makes little sense to
help a person with diabetes build self-efficacy at self-injection with
out providing that person with the behavioral capability to self
inject, ways in which to fit this behavior into his or her life, and
suggestions about how to cope emotionally with having diabetes.
Although some variables may be more important in certain situa
tions than others, most apply in a most any area of health educa
tion. The health professional must therefore explore the ways in
which multiple variables are manifested in particular situations and
plan interventions that are based on multiple relevant concepts.
Summary

This chapter has focused on Social Learning Theory and its rele
vance in the design of health education programs. By incorporating
a concern for environment, people, and behavior, SET provides a
framework for designing and implementing comprehensive behav

potent environment for learning eating patterns, seemed critical for
behavior change.

ior change programs.
Social Learning Theory is an attractive theory to apply to

Caveat

health education and health promotion programs because it not
only illuminates the dynamics of ir dividual behavior but also gives

An important caveat is in order. In the development of SET con

direction to the design of intervention strategies to influence behav
ior change. A large number of intervention studies that provide

cepts over the past decades, one concept was often explored while
the others were excluded completely. For example, the concept of
internal and external locus of control dominated social learning

research at one time. Later, the concept of observational learning
was used extensively to explain learning among children. In 1982,
Bandura stated that self-efficacy may be the single most important
factor in promoting behavioral change. This emphasis on a single
variable is a reflection of the structure of experimental research,
which usually permits analysis of only a few variables at a time; the
problems that are selected for analysis; and the tendency for fads to
develop in all types of research.

support for the effectiveness of SET as a theoretical base for promot
ing health behavior change have been conducted.
In the development of health promotion programs, great em
phasis is placed currently on the importance of multicomponent
interventions. Recent approaches are including interventions that
address not only behavioral change at the individual level but also
change within the environment to support behavioral change
(Simons-Morton, Simons-Morton, Parcel, and Bunker, 1988; Parcel,
Simons-Morton, and Kolbe, 1988). SLT can be applied to the multi

level change strategy because of the inclusion of environmental,
personal, and behavioral constructs. The ability of SLT to address

182

Health Behavior r

Health Education

all three domains can contribute to the design of multicomponent
health promotion interventions.
As reviewed in this chapter, SLT is a robust theoretical
framework that can be applied to health education and health pro
motion activities with as much diversity as individual counseling,
community-based interventions, and the diffusion of innovative
programs. However, inappropriate applications of SLT sometimes
occur because of an oversimplification of the intervention methods.
To guard against inappropriate applications, designers of interven
tion strategies should first specify the desired behavioral outcome
and identify the SLT variables most likely to influence changes in
the specified behavior. Then SLT intervention methods can be
matched with variables targeted for change to influence the desired
behavioral outcome. The final step is the creative part of health
education: translating the theory into practical and meaningful in
tervention strategies that can work in the real-life settings of health
education programs.
References

Argyle, M., Furnham, A., and Graham, J. A. Social Situations.
Cambridge England: Cambridge University Press, 1981.
Bandura, A. “Social Learning Through Imitation.” In M. R. Jones
(ed.), Nebraska Symposium on Motivation, Vol. 10. Lincoln:
University of Nebraska Press, 1962.
Bandura, A. Principles of Behavior Modification. New York: Holt,
Rinehart 8c Winston, 1969.
Bandura, A. Psychological Modeling: Connecting Theories. Chi
cago: Aldine/Atherton, 1972.
Bandura, A. Social Learning Theory. Englewood Cliffs, N.J.:
Prentice-Hall, 1977a.
Bandura, A. “Self-Efficacy: Toward a Unifying Theory of Behav
ioral Change.” Psychological Review, 1977b, 84, 191-215.
Bandura, A. “The Self System in Reciprocal Determinism.” Ameri
can Psychologist, 1978, 33, 344-358.
Bandura, A. “Self-Efficacy Mechanism in Human Agency.” Ameri
can Psychologist, 1982, 37, 121-147.

Individual® Environments, and Health Behavior

183

Bandura, A. Social Foundations of Thought and Action. Engle
wood Cliffs, N.J.: Prentice-Hall, 1986.
Bandura, A., and Adams, N. E. “Analysis of Self-Efficacy Theory of
Behavioral Change.’’ Cognitive Therapy and Research, 1982, 1,
287-310.
Bandura, A., Adams, N. E., and Beyer, J. “Cognitive Processes Me
diating Behavioral Change.’’ Journal of Personality and Social
Psychology, 1977, 35, 125-139.
Bandura, A., and Walters, R. H. Social Learning and Personality
Development. New York: Holt, Rinehart 8c Winston, 1963.
Baranowski, T., and Nader, P. R. “Family Health Behaviors.’’ In D.
Turk and R. Kerns (eds.), Health, Illness and Families. New
York: Wiley, 1985a.
Baranowski, T., and Nader, P. R. “Family Involvement in Health
Behavior Change Programs.” In D. Turk and R. Kerns (eds.),
Health, Illness and Families. New York: Wiley, 1985b.
Bates, J. A. “External Reward and Intrinsic Motivation: A Review
with Implications for the Classroom.” Review of Educational
Research, 1979, 49, 557-576.
Bern, D. J. “Self-Perception: An Alternative Interpretation of Cog
nitive Dissonance Phenomena.” Psychological Review, 1967, 74,
183-200.
Block, J. H. (ed.). Mastery Learning: Theory and Practice. New
York: Holt, Rinehart 8c Winston, 1971.
Bronfenbrenner, U. “Toward an Experimental Ecology of Human
Development.” American Psychologist, 1977, 32, 513-553.
Condiotte, M., and Lichtenstein, E. “Self-Efficacy and Relapse in
Smoking Cessation Programs.” Journal of Consulting Clinical
Psychology, 1981, 49, 648-658.
Diaz-Guerrero, R. “The Development of Coping Style.” Human
Development, 1979, 322, 320-331.
DiClemente, C. C. “Self-Efficacy and Smoking Cessation.” Cogni
tive Therapy and Research, 1981, 5, 175-187.
Ewart, C. K., Taylor, C. B., Reese, L. B., and Debusk, R. F. “Effects
of Early Post-Myocardial Infarction Exercise Testing on Self
Perception and Subsequent Physical Activity.” American Jour
nal of Cardiology, 1983, 57, 1076-1080.

200

G. MORAN

Health” in September 1983 (Sheffield Health
Care Strategy Group, 1984, 1985) and regular
meetings of interested authorities are being held,
serviced by the Leeds City Council Health Unit,
to enable authorities to learn from the successes
and failures of experiments elsewhere. On
specific issues, such as smoking or food, the
broad outlines of appropriate local authority
policies are becoming clearer and attracting
considerable attention, while a number of
authorities have undertaken systematic research
in the form of a locally-based "Black Report” as
a starting-point for reviewing the effectiveness of
their services in promoting the public health.
Nationally, the Association of Metropolitan
Authorities, the representative body for major
urban authorities, is creating a new health forum
within its structure and the Health Education
Council is also keenly interested in becoming
involved in this developing area of health pro
motion work.
Valuable though these local authority initia
tives are, however, they occur within a national
context deeply hostile to the collective impli
cations of many health promotion initiatives—a
hostility which is evident in both ideological
debate and specific resource allocation decisions.
Ideologically, regulations which were once
explicitly framed to promote the health of both
communities and individuals, such as planning
law and the Health and Safety at Work Act, are
now attacked as mere "red tape” which obstructs
economic regeneration and national prosperity.
Resource allocation decisions reflect this
antipathy to public intervention even in areas
where the beneficial health impacts have
Historically been acknowledged—most notably in
housing. If this climate of hostility to health pro
motion by structural rather than individual inter
ventions is to be encountered, local authorities
will need to mobilise both their technical skills in

I
documenting existing shortcomings and, crucially,
the specifically political authority which derives
from their status as democratically elected
bodies. While the difficulties involved in doing
so are formidable, the renewal of the public
health tradition in local authorities remains cen
tral to any broad strategy for health promotion.
In the 4>ast five years, a small but growing
number of authorities have begun to acknowl
edge the importance of this issue. It remains to
be seen whether they are capable of achieving
this renewal and of bringing with them those
many local authorities in Britain whose commit
ment to public health as a major part of their
activity has been allowed to wither since 1974.

REFERENCES
Brewer, R. C. (1986) The Local Authority Associations and
ihg Reorganisation ol the National Health Service in
1974. Voliurna Press.
Brown. G. W. A Harris. T. (1978) Social Origins of Dep
ression. London: Tavistock.
Byrne. D.. McCarthy. P., Keiihley. J. A Harrison. S. (1985)
Housing. Class St Health: an example of an attempt at
doing socialist research. Critical Social Policy, 13. 49-72.
DHSS (1977) Prevention and health: everybody’s business.
London: Department of Health and Social Security.
DHSS (1980) Inequalities in Health. London: Department of
Health and Social Security.
Eskin. Prada (1985) Guardians of the Public Health.
London: Health A Social Services Journal 24 October
1985. 1328-9.
Godber. G. E. (1986) Medical Officers of Health and Health
Services Community Medicine, 8, I. 1-14.
Gyford. J. (1985) The Politics of Local Socialism, London:
George Allen St Unwin.
Sheffield Health Care Strategy Group (1984) Progressive
Strategies for Health Conference Papers. Sheffield City
Council.
Sheffield Health Care Strategy Group (1985) Progressive
Strategies for Health, 2. Sheffield City Council.
Unit for the Study of Health Policy (1979) Rethinking
Community Medicine. London: Guy’s Hospital Medical
School.

Vol I. No. 2
Panted in Great Britain

HEALTH PROMOTION
Oxford Univertily Preu I9M

When health promotion works, the opposition
begins: A personal view
JAMES COWLEY
Director of Health Promotion Services, South Australian Health Commission 1980-1985

INTRODUCTION
We have all been there. Most of us have taken
part in those endless debates about the theory of
health education and health promotion; those
debates on terminology and the endless argu
ments about whether it is possible to change
behaviour.
Many of the colleagues I had worked with had
recognised that beyond those theories of health
education and health promotion, were many
other disciplines and activities which had no
problem at all in motivating, changing and shap
ing human behaviour. Having increasing contact
with politicians and others who had to imple
ment policy in nations or regions it became cleur
that the theory meant nothing to them; and that
even if interested in the subject they needed
action and results.
A third question was growing in my mind. If
health promotion did work . . . Wouldn’t that
produce some pretty big potential changes which
may touch the raw nerve of the many and varied
vested interests groups . . . What would it be like
if that happened and could we learn something
from it?
With this concern over the relevance of much
theory; acceptance of the need for results, not
thoughts or words, and an anticipation that if it
worked then it may open up a whole new field of
questions, 1 accepted the position of director of

The author would like to retain contact with those
working in the field of health promotion and can
be contacted at the following address: GPO Box 640,
Adelaide SA 5001, South Australia.

health promotion in a government commitied to
results, with a Minister and chairman supportive
of the concept of health promotion.
The case study that follows is naturally a biased
account, but a number of my colleagues believed
that those parts which could be written up should
be. The results quoted are not biased. Indepen
dent research reports exist wh'ch describe them.
The end came after a change in government
and a new Minister a new Chairman and
reorganised Commission had taken over. The
end, amidst a party political uproar demon
strated all too clearly that health promotion is
political. When it works, the opposition begins.

BACKGROUND
South Australia, the Slate being described, has its
own parliamentary system of upper and lower
Houses, its own Cabinet, its own health, educa
tion and social welfare systems. It has extensive
media coverage through electronic and other
media. It has a Health Commission, answerable
to the Minister of Health who is a member of a
Parliamentary Cabinet. It also has over 100 local
councils voted into power on a non-party basis.
It has large blue-collar industrial areas, large
white-collar areas and is spread over a geo
graphical area over five times the size of the
British Isles.
My experience of South Australia is that it is a
microcosm of the powers, pressures, problems
and opportunities which I had seen operating in
much larger populations. The processes of
government, the problems of the health and
291

202

WHEN HEALTH PROMOTION WORKS, THE OPPOSITION BEGINS: A PERSONAL VIEW

J. COWLEY

welfare systems, the influence of vested interest
groups, the economic prognosis, the patterns of
youth and other age group unemployment, and
an ageing population are all comparable to other
Western nations. The size of the community
allows a closer insight into (he decision-making
processes and the pressures on government
policy related to health. Naturally there arc many
subtle differences, but for the purpose of this
study much is comparable with other Western
nations.
The government, Minister and Chairman of the
Health Commission who established the health
promotion services wanted us to demonstrate
either that health promotion worked or didn’t
work. They were not interested in just words and
hopes. While that government, with its emphasis
on innovative programmes remained in office,
the mandate was there to develop a fast-moving
results-orientated service. Without that support
at the highest levels it soon became Impossible to

operate in the same way.

INITIAL AIMS
The initial aims were quite straightforward for

the first three years:
• We needed to demonstrate that preventative
programmes worked.
• We needed to get preventative programmes
away from therapy and into normal life. The
dominant social welfare ideology which
reduced people to being recipients of a welfare
stare, with no self esteem and organised by the
next wave of social idealists who always knew
best, had to be challenged. The aim was to en
courage people to be health consumers, mak
ing choices about how to remain healthy,
rather than be subjugated by the popular
welfare concepts of illness and dependence.
• We needed to influence the health system in
such a way that it would accept health promo
tion as a legitimate long-term component of
the system, and would eventually recognise the
preventative component of many parts of its
work.
It was dear that unless the first results
demonstrating the success of health promotion
were available within two years after its incep
tion, there would be growing opposition to spend
ing in that aret while cuts were taking place
elsewhere.

Myths abounded immediately about the
amount of money being spent on this new
approach, but the truth is that even today, the
budget represents a minuscule section of the
health budget.
It waa obvious that a strong organisation had to
be developed to carry out the task. An initial
feasibility study was carried out, looking at the
capabilities within various organisations for
preventative programmes, and meeting a wide
cross*scction of people within the State to discuss
needs in health promotion. To this was added the
advice of an excellent epidemiology department,
which was able to pinpoint major aspects of
preventable ilbhealth. Added to these perceptions
were the policies of the government in such areas
as drug abuse prevention, smoking reduction, im
munisation and breast cancer reduction, as well as
a general dissemination of knowledge about
health to the population.
The feasibility study identified clearly that
many organisations and groups were involved in
health promotion, but there was a need for:
• an organisation that could run large-scale
media and community programmes
• the availability of good quality materials and
publications which people could choose to
obtain, to help them with questions about their
health
• opportunities for more health professionals to
learn health promotion skills
• systems for information, collection and
dissemination of both successful and unsuc
cessful programmes
• facilities for the proper use of epidemiological
and other data in planning programmes and to
research the outcome of programmes.
• an advocacy group which could suggest policy
in health promotion and who could initiate
action leading to more attention to health rather
than illness.
The existing unit was not operating in th s way as
much of the work had been “face to face” work
within the community, or in schools, or in the
training of professionals. As the new unit was to
have a central function, new people were needed.
The initial staff brought to the organisation a
broad range of experience from many fields un
connected to health education and promotion.
The team which emerged included people who
were experienced in putting together large-scale

ments are so far apart as to make it nearly
impossible to maintain an innovative team.
The
organisational
structure
that
was
developed is shown in Figure I. The programmes
were based on a very simple model which could be
understood easily and communicated to anyone.
The first stage was to define the prob
lem from epidemiological, socio-psychological,
environmental, marketing and other data. Once
the problem was defined, a range of strategies was
chosen to attempt to help to reduce the problem in
the community. The model has been illustrated as
in Figure 2.
The following summaries cover a number of
the programmes which were established in South
Australia, and demonstrate that health promotion
works.

community and media programmes; a world-class
creative director from New York; researchers,
political scientists, publishers, an entrepreneur to
run a city centre shop, journalists and others of
similarly diverse backgrounds. Most had one
common factor—they were used to being paid for
results rather than talking about the possibility of
getting results.
A team of more than 30 such people is dynamic,
but also requires massive flexibility as the ap
proaches of each discipline can be different. In the
end
I
concluded
that
it
was
imposs
ible for such a team to function properly within
the public service. The distinct differences
between modern management styles seen in
business which can nurture such a team, and the
management styles encouraged in health depart-

Figure 1: Structure of the organisation
Director

Administration and Clerical Teams

Operations
Manager
Programmes

I

Programme
Manager

I

Health
Development
Unit
Manager
(A Programme
' Manager)

I

Marketing
and
Promotions
Manager

Services

I

I

Media
Manager

Creative
Manager

i

Research
Manager

Campaigns

Professional
intervention
and retraining

Use of media

PROBLEM

Fiscal policy

Legislation

Support for the
continuation and development
of services (medical,
community health, hospital)

Treatment

Influencing
policy

Changes in
technology

Environment

Education through
schools, community and
(he media

I

Production
Manager

Figure 2: The range of strategies
Support for
community
development

203

.'04

WHEN HEALTH PROMOTION WORKS. THE OPPOSITION BEGINS: A PERSONAL VIEW

J. COWLEY

It is crucial to recognise that the strength of the
programmes lay in the massive involvement of
many groups and organisations within the com
munity, and was not due simply to only one
organisation which was coordinating the pro
grammes centrally.
The programmes are set out under the follow
ing sections:
1. Statement of problem
2. Major strategies
3. Results
4. Main vested interest opponents
5. Costs of programme per head of population,
including staffing from the health promotion
services but excluding community support
costs
Programme to Reduce Tobacco Smoking

1 Statement of problem
About a third of the population was smoking
tobacco. Marketing of tobacco is aggressive in
Australia. Large-scale demographic research was
carried out across the State to determine the
nature and scope of the problem and to gain a
variety of community opinions. The research
showed substantial support for action in this area
with over 80 per cent supporting government
campaigns. Two programmes of market research
were then commissioned which segmented
smokers and provided insights into the moti
vations of smokers concerning giving up smok
ing. (Steidl and Cowley, 1982) (Bowden, 1984)
Concept-testing market resekrcltyas then carried
out and a range pf communications which would
be successful was determined.
2 Major strategies
Media: A six-week mass-media programmes was
run using a commercial at the start of the com
mercial break, which raised emotional feelings
over smoking, and one at the end of the break,
which demonstrated conditions under which
smokers were “tempted” to start smoking again.
One of these commercials was the highly ac
claimed one from Bernie McKay’s New South
Wales North Coast project, as it was not worth
creating a new product if one worked well
already.
Six weeks of radio commercials were created,
again based on market research, and written

around testimonials of people trying to stop
smoking. Six weeks of informal news cover was
organised to generate massive community discus
sion.
A school programme was run by teachers
simultaneously and a professional manual was
written to bring all professionals up to date.
Doctors were given material for patients;
hospitals were involved in giving out material;
and numerous community groups were involved.
A small number of "stop smoking” groups
was organised for the few people who needed
group counselling to help them give up. Shop
ping centre displays were organised. Local com
munities organised barbecues and runners ran
between the towns carrying a collection of
signatures which thanked the government for its
assistance in this area. These petitions were
flown to the capital city and presented to the
government by the State Australian Medical
Association.
Work was carried out through industry to pro
vide no-smoking working environments.

3 Results
Based on substantial advice from experimental
researchers and the Australian Bureau of
Statistics, a household survey was carried out
three months after the programme was concluded.
The experimental area experienced a drop of 11.4
per cent of smokers maintained over three
months. The control area experienced a 4.9 per
cent drop but this was probably artificially
higher than the normal, due to the intervening ef
fects of another State’s campaign. Normal rates
In one town 13.5 per cent of the population
maintained cessation and,'interestingly, it was
this town where we received the most opposition
to the programme from welfare workers, who
did not feel the subject was really appropriate.
The towns were predominantly blue-collar areas.
(McDonald, 1983)

4 Main vested interest opposition
The major opponents were undoubtedly some
health and welfare workers. They rated smoking
as a low priority. They also objected to the use of
mass media. Others believed that work should be
done through stop smoking groups in face-toface therapy. We found that only 2 per cent
actually needed this type of help.

205

Luckily, the majority of community health
workers were strongly supportive, and the pro
gramme benefitted considerably from their sup
port, but the vocal minority were a constant
presence.
Before the programme even started some
academics opposed it on the grounds that it was
ideologically unsound. Oneof the strikingdemon
strations of this bias was where the minutes of one
committee proclaimed that “the quality of the
research is to be doubted and the results in
conclusive”. At that stage, the research report had
not been finalised, had not reached the research
manager, myself or the Minister and could not
have been studied by anyone.
The industry naturally opposed schemes that
would influence what it saw as a legitimate and
legal right to sell a product. In South Australia
generally, the industry took a low profile.

established. Concept testing was carried out by
female researchers. (Bowden, 1982) (Bowden.
1984)

5 Cost of programme
The cost of the programme was about $5 per
head of population for the pilot scheme and
40 cents for the later State-wide scheme.
The programme was taken State-wide but fail
ed to provide comparable measured results. The
main reasons seemed to be
• the funding was too low (40 cents compared
with S5 per person, as the original budget had
been progressively reduced).
• there was a repositioning of some tobacco
brands about the time of the follow-up survey
which would have increased smoking in some
segments and influenced the sample.
• the level of informal news cover was consider
ably lower.

3 Results
A 16 per cent self-reported increase occurred in
breast self-examination. In the three-month
follow-up period there was a 30 per cent increase
in cancer detection rates. A 53 per cent increase
in cancer detection rates for women under 50
years of age and a 21 per cent increase for those
over 50 years old occurred. The proportion ol
cases with four or more affected nodes at
diagnosis was substantially reduced. There was a
decrease in tumour size. (McDonald. 1982)

It was interesting to note that the failure of this
one programme created more interest than the
successes of all the rest put together. The others
were diminished in the light of this one failure. In
other fields of behavioural change such as
advertising, it is well recognised that there are as
many failures as successes, whereas the demands
on prevention are both high and unrealistic.

Programme to Increase Breast Self-examination
I Statement of problem
Epidemiological research together with federal
recommendations showed the need for action in
the area of breast cancer. Baseline data on breast
self-examination, biopsies and attitudes was

2

Major strategies

A television commercial, using a doctor as an
authoritative figure (shown to be essential by the
market research) demonstrated breast self
examination. Large-scale informal press cover
was organised. Posters were developed for
display places frequented by women. Many
women’s groups were involved, and community
health centres arranged meetings. Demonstration
breasts were available with teaching materials in
the women’s lingerie departments of large stores.
Teaching packs were developed to train health
professionals, and large numbers of community
groups were involved. Seminars for health pro
fessionals were run.

4 Main vested interest opponents
There were few vested interest opponents—
primarily a very small number of medical
specialists who feared money may be diverted
from treatment and a minority group in the
women’s movement.
5 Costs of programme
The costs of the programme were 5 cents per
person excluding manpower costs and 20 cents
per person in all.

Immunisation Programme
I Statement of the problem
Only 50-55 per cent of children were receiving
measles vaccine: 360 cases per year needed
hospitalisation due to measles. Twenty-seven per
cent of 21-30 year old females were not immune
to rubella. Market research into concepts related

206

J. COWLEY

to rubella was established and materials tested.
(Bowden, 1981)

WHEN HEALTH PROMOTION WORKS. THE OPPOSITION BEGINS: A PERSONAL VIEW

CARDIO-PULMONARY
RESCUSCITATION PROGRAMME

2 Major strategies
Television commercials which had been market
tested, radio commercials, and a controversial
poster on the rubella theme were developed. In
formal news cover on the themes related to im
munisation were developed to keep the story
alive in the minds of the public.
Attention was given to community groups to
encourage them to cover the subject and the
knowledge of professionals on immunisation was
updated. Services were made more read'ly
available through local councils and schools to
enable easy access to immunisation.
In a follow-up programme aimed at specific
ethnic groups, substantial work was carried out
through the ethnic community networks.

1 Statement of the problem:
More pedple could survive accidents and heart
attacks n more of the population were trained to
carry out resuscitation.

3 Results
Main programme: Measles immunisation rates
up 64 per cent: rubella rates up 57 per cent.
(SAHC, 1982)
Follow-up programme: South-east Asian triple
antigen rates increased 42 per cent, poliomyelitis
rates increased 28 per cent. One of the major
failures of the supplementary stages of the pro
gramme was in trying to aim at too many ethnic
groups at once. While the rates in ethnic groups
continued to keep pace with general immunisation
rates due to the programme, the very high in
creases seen in the south-east Asian community
did not occur across all groups. The evidence
suggests that with restricted resources, only
one ethnic group at a time should be worked
with.

3 Results
In the 18 months of operation, eight lives were
saved directly due to the programme.

4 Main vested interest opponents
Some community health workers did not like the
use of the media: Some women’s movement
members did not like the emphasis on women
being immunised against rubella, although this
was offset by a massive reaction from women in
the community at large with over 80 per cent of
women approving of the programme.
5 Costs of the programme
The costs of the programme were three cents per
person excluding manpower costs and 15 cents
per person in all.

2 Major strategies
This was a community generated scheme with the
assistance of a hospital, St John’s, Red Cross
and later Apex, Woolworths and an advertising
agency. The Health Commission provided the in
itial finance and assistance with media promo
tion of the scheme, sponsorship seeking, and
publishing. The main strategies were mass
publicity for the scheme, teaching small groups
within the community, and mass media en
couragement of people to participate.

4 Main vested interest opponents
Very few.
5 Cost of the programme
Three cents per head of population. (Govern
ment money before sponsorships).
There were many other programmes, each with
differing emphases, using different combinations
of strategies, but there is not sufficient space to
go into them all in detail. However, some are
worth a brief mention:
• A health promotion programme on the elderly
to assist families in caring for elderly relatives
with senile dementia. This consisted of support
ing a voluntary group, assisting them in the use
of the media and pretesting and publishing a
booklet for families. The cost was one cent per
head of population. (Manfield, 1983)
• A daily physical fitness programme in schools
which led to significant measurable changes in
physical health of children lifestyle, behaviour
and body knowledge. Some of the initial opposi
tion to this programme came from traditional
health educators in schools, concerned that the
emphasis of schools should be more related to
self-esteem and relationships than to physical
health. This project as a bi-product, raised

children’s self-esteem. The cost was 12 cents per
head of population.
• Accidents in industry programme concen
trating on uniting unions and management in
implementing primarily environmental changes
in factories. The pilot project showed a drop
from 428.2 hours lost through accidents to 56
hours lost in a comparable eight-month period.
This was a successful pilot programme run jointly
with the National Safety Council. (National
Safety Council, 1982)
• Alcohol, driving, and the 16-24 age group: A
large-scale media and community involvement
programme was run. Due to research para
meters, death rates could not be compared,
but accident rates in this age group dropped in
the period of the research, (McDonald, 1984)
• City centre shop: A highly innovative project
was developed to try to develop a central shop in
the capital city centre where people could come
as consumers of health information. Various
shop displays were developed which had massive
consumer appeal. Large numbers of people used
the shop and many organisations used it as a way
to contact the general public in a non-therapeutic
context.

THE END OF THE EXPERIMENT
Following these short-term successes, c< nsiderable effort was put into developing a Health
Commission policy on health promotion, initiat
ing research work to retarget programmes over
longer periods of time and starting to aim to
create long-term maintained positive trends in
health indices. (Cowley, 1982; Laurence, 1984)
The experiment had been based around the
central tenet of showing results which could be
measured. The methods we used were acclaimed
by many international visitors and the style of
management related to innovation and entrepreneurism with a team within the public sector,
was seen by many as quite different from many
traditional approaches to health education and
the health services.
One of the great encouragements of the experi
ment was that other governments asked for
reviews to be carried out on their own health
promotion organisations and new ones were
established based on the South Australian
experience. (Cowley & Rubinstein, 1982;
Cowley, 1982, 1983, 1984)

207

The end of the experiment is now widely
known. The Government changed, the Minister
changed, the Chairman changed. Relationships
became strained. A review of health promotion
was instigated by the Office of the Minister. The
results of the review were presented under Parlia
mentary privilege, a setting in Australia which
allows no legal redress through the normal laws
of defamation.
The final discussions ignored the results and
the recognition of what had been achieved, but
rather concentrated on the intangible and
debateable issues of management styles, a certain
winner because management styles of innovative
groups and private enterprise managers are
always different from those of the public sector.
The conclusion was drawn that radical changes
were necessary and I resigned as director together
with a number of other staff who moved on,
amid a political uproar between the two parties.
The trend has been back towards approaches not
dissimilar to those when the whole experiment
began.

WHAT OPPOSITION STARTED
WHEN HEALTH PROMOTION WORKED?
There were a number of areas where the raw
nerves of vested interests were touched:

I Health care professionals:
curative and medical technology
We generally received considerable support frorr
the medical profession. They showed a high com
mitment to health promotion and the major pro
fessional medical groups were exceptionally
supportive. There were a number of issues how
ever which were the basis of some opposition:
• An inability to understand what health is
among some health planners. Generally health
planners have to deal with balancing accounts
and ensuring hospitals do not overspend. It is
a huge step to move from this to more general
thinking and long-term planning concerning
how the actual nature of health experienced by
the population can be improved. Some health
officials could never get beyond seeing health
promotion just as a short-term fad.
• An inability of health systems to look at effec
tiveness as much as efficiency. The systems
concentrate on whether money adds up, not on
whether expenditure in one area equals greater
benefit than expenditure in another area.

G

208

J. COWLEY

WHEN HEALTH PROMOTION WORKS. THE OPPOSITION BEGINS. A PERSONAL VIEW

• Health innovations usually have to be funded
within standstill budgets.
• Much time is spent in health departments try
ing to survive the next political crisis rather
than on long-term planning.
• Medical practice vested interests sometimes
felt that it was their money being spent on
health promotion. They thought that if one
part of the system had been cut it must have
been that money which was being spent on
health promotion.
• A belief that health promotion is extremely
expensive. $100,000 spent on a campaign was
seen as gross over-expenditure, while ten times
that amount being spent each day on equip
ment was seen as necessary.

2. Health and welfare professionals In
preventative work and community work

While most welfare workers supported the pro
grammes. sadly, a vocal minority group opposed
them. The major problems they raised were that:
• Programmes needed to move at speed and be
tuned in to consumer needs rather than be put
together by endless committees. Some workers
rejected this.
• There has been a tendency for some of the
intellectual left of the welfare movement to
develop the "gobbledegook" and "rhetoric"
of the journals with buzz-words like "com
munity development" and "community
involvement" while at the same time having
little real-life involvement outside their jobs
with the community in which they work. They
are the modern day missionaries: they com
mute from England to Africa but don’t sleep
there: they tour in from their comfortable
intellectual leftist environments with their aim
to correct communities’ "problems": they
hurry out quickly if there is the suggestion that
they should shop, drink or otherwise mix in
normal ways within those communities.
In the end these were the most influential
vested interest groups. Their response to every
thing was “but”. They asked: "Is it appropriate?"
or "Is it ideologically sound?" "Has there been
enough consultation?” and many other ques
tions which destroy and tear apart the possibility
of action. The theorists have based their
disciplines on a negativism that cripples inno
vation and real social caring in our society. It

reduces everything to descriptions and never
looks for results.

• Some workers had an opposition to media.
• Some workers argued always for more consul
tation with everyone who worked in or on the
community. Rarely did they suggest actually
asking members of the community them
selves.
• Some always wanted more research to be
done, as if repetitive research were a selfperpetuating amoeba, making the problem
easier to define.
• Some always said more resources were neces
sary, while failing to realise the resources
already provided by the State.
• Some always argued for face-to-face work,
while failing to accept the cost of such
approaches and the unwillingness of the
majority of the population to be treated as
"clients" who needed help and had to be treated
in therapeutic ways.
• Most of those who opposed the programmes
misrepresented the communities in which they
worked. They saw the communities through
their commuter eyes; they denigrated the
working class culture by accusing them of
being too consumption orientated; they
criticised what they perceived as bad paren
ting; they accused them of being socialised into
not understanding leftist or extreme feminist
ideologies and they developed programmes
aimed predominantly at producing the tran
quilliser of identity-seeking, rather than help
ing people to take pride in the cultures to
which they belonged.

POLITICAL VESTED INTERESTS

Health is political and health promotion is
political. Issues which need to be recognised
include:

• the development of the "media politician"
figure across the world, who desires policies
and programmes which reflect on his image.
• The increasing demand by governments for
short-term rather than long-term results.
• The need to respond to popular crises like
AIDS, drugs or glue-sniffing, the publicity of
which may be out of proportion to the epi
demiological realities.
• The need for Ministers to survive politically.

INDUSTRIAL VESTED INTERESTS
Vested interests do oppose health promotion.
There are numerous examples of the use of cor
porate pow?r to lobby and influence decisions.
The health promoter has to understand^however,
that they see their action as totally necessary and
that they are trying to preserve jobs and
economic stability.
Perhaps one of the most important areas for
the future is for health and industry to get
together more to look at whether it is possible to
develop both health and economic prosperity.
The strongest commitment needs to be made to
such negotiations.
WAS IT ALL WORTHWHILE?
The first five years of the experiment in South
Austraha showed many lessons for the develop
ment of health promotion:
It confirmed that:

• measurable results can be achieved.
• a problem-solving approach to health promo
tion can produce effective strategies.
• media, community development, training,
political action, are not mutually exclusive but
can all be used in parallel.
• if the emphasis is on doing rather than theory,
results can be achieved.
• health promotion can be linked closely to the
medical profession.
It also showed:
• That health promotion is politically volatile.
• That health promotion touched the raw nerve
of many types of vested interests.

209

• The need for a holistic ecological approach
which links health development to other
aspects of society, particularly economic and
industrial development.
REFERENCES
Bowflen. M. R.. (1981) Immunisaiion advertising concepitesiing. South Australian Health Commission.
Bowden, M. R.. (1982) Breast self-examination. Marketing
communication concept-testing. SAHC.
Bowden, M. R., (1984) Breast self-examination: A study of
new communication strategies. SAHC.
Bowden, M. R., (1984) Smoking behaviour and attitude
change: Advertising concept-testing. SAHC.
Cowley, J. C. P. 4 Rubinstein, P. (1982) The preventative
and health education role of student services in ternary
education. In Row E., Tertiary Education in Australia
Tertiary Education Commission.
Cowley. J. C. P , (1982) Discussion paper for ihe South
Australian Health Commission as a basis for a policy
statement on health promotion. SAHC
Cowley. J C. P (1983) Review of health promotion and
education for the Minister of Health. Western Australia
SAHC.
Cuwley, J. C. P. (1984) Review of health promotion,
education and information in New South Wales SAHC
Laurence. H. (1984) Making South Australia a Healthy
State. SAHC.
Manfield. C . Prochazka. Z.. Henschke. P . Skinner. E. and
Last. P. (I98J) Memory loss and contusion: Dementia
SAHC.
.McDonald. H
(1982) South Australian breast selfexamination campaign report. SAHC.
McDonald. H. (1983) South Australian pilot stop-smoking
campaign reports SAHC
McDonald. H. 11984) A programme to combat drinking and
driving in 16-24 age group. SAHC.
National Safety Council. (l°8<.) Management by objectives.
National Safety Council, Adelaide. SA.
South Australian Health Commission. (1982) A short-term
evaluation of the SA immunization promotion campaign
Epidemiology branch.

L

(S.O1M H
HEALTH PROMOTION
©Oxford University Preu 19R9

n s.

Vol. 4. No 4

Printed in Grew Britain

Some problems in heail^promotion research
MICHAEL P. KELLY
Senior Lecturer in Health Promotion, Department of Community Medicine, University of Glasgow

SUMMARY

It is argued that health promotion research faces three
critical problems: defining adequate research questions:
identifying appropriate areas for research and develop
ing a theoretical basis for problem formulation. Il is
suggested thai if health promotion research is to be a
vigorous pan of the emerging discipline of health
promotion, rather than simply an evaluative tool, and if
health promotion research is to be distinguished from
epidemiology, sociology, psychology, politics or eco
nomics with a health promotion angle, then these three
problems must be resolved. The origins ofthe difficulties
a'sociated with problem definition, priority areas for
research and adequate theoretical tools are traced in the
first instance to the idealistic and programmatic nature

of health promotion and the conflation of is' and ought
to be’questions in the idealism. The ought to be'nature
of health promotion carries important implications for
behavioural and social change. It is argued that for the
most pan the normative and scientific issues surround
ing change have not been disentangled and that neither
have the contributions of the disciplines which have
studied social and behavioural change had much
impact on health promotion. These problems manifest
themselves in studies and practice involving empower
ment, enablement and healthy public policy. It is
concluded that the role of research in health promotion
must be clarified and a shift away from the pathogenic
paradigm encouraged.

INTRODUCTION

The emerging discipline of health promotion and
the activities and practice called health promotion
suggest themselves as- areas where a sound
research base should be developing hand in hand
with the subject. However, it will be argued in this
paper that if the research task of health promotion
is to be more than evaluation of practice and more
than epidemiology, sociology, psychology, poli
tics or economics with a health promotion theme
or angle, then considerable practical and theoret
ical problems arise. In activities like community
development. Health for All, and Healthy Cities,
for example, not only is it sometimes difficult to
identify meaningful research fas against evalua
tion) questions, but also proolem definition is
compounded by issues of why particular things
come to be seen as areas worthy of research, and
how they are to be analysed and investigated. This
paper explores these things.
The text is divided into six parts. In the first, the
problems of researching a set of ideals and goal

oriented programmes are raised. In the second
section, the implications for research of the
assumptions of the desirability and possibility of
social and behavioural change often associated
with health promotion, are analysed. In the third
section, the models of empowerment, enable
ment, participation and healthy public policy are
discussed. In the next part of the paper, the focus
is on the question of the differing paradigms of
human behaviour impinging on health promotion
practice. Finally, the role of research vis-a-vis
practice, vis-d-vis client groups and vis-d-vis
professional peers is described. The paper con
cludes with a consideration of the salutogenic
model for research in health promotion.

317

co
to

318 M.P. KELLY

THE IMPLICATIONS FOR RESEARCH OF
THE IDEALISTIC AND PROGRAMMATIC
NATURE OF HEALTH PROMOTION

One of the most distinctive features of the World
Health Organization's approach to health promo
tion is its idealistic and programmatic character.
Goals and desired future states are identified and
these are accompanied by normative exhortations
for generalized improvement. The Ottawa Char
ter for Health Promotion (WHO, 1986) is a good
case in point. It defines health promotion as ‘The
process of enabling people to increase control
over and improve their health’ (my emphasis).
This process, it is argued, is premised on certain
basic prerequisites for health—peace, shelter,
education, food, income, a stable eco-system,
ustainable resources, social justice and equity.
The principal means of attaining these objectives,
according to the Charter, are political. They
involve advocacy, which will ensure that health
ippears on the political agenda, and they involve
enablement, which will allow people to achieve
their fullest health potential. It is explicitly
recognized in the Charter that the processes will
involve the mediation of differing interests in
society. The Ottawa Charter therefore identifies
the building of healthy public policy, the crea
tion of supportive environments, the strengthen
ing of community action, the development of
personal skills and the reorientation of health
services as the key strategics in the overall
process. The ideals of improvement and change
ilong with a political programme are juxtaposed
to provide a de facto definition of health promo
tion.
The ideals of improvement and change also
formed the core of an earlier WHO document
entitled Health Promotion: Concepts and Prin
ciples in Action: A Policy Framework (Nutbeam,
n d.). Here the principles of health promotion are
identified as: involving the population as a whole
in the contexts of their everyday lives (rather than
populations at risk from particular diseases); as
being directed towards action on the determin
ants of, or causes of health; as being diverse in
methods and approach; as involving effective and
concrete public participation; and as not being a
medical specialism (Nutbeam, n.d., p. 4). The
principles are the basis for what Nutbeam calls
the subject areas of health promotion. These are:
access to health, development of an environment
conducive to health, strengthening social

networks and social support, promoting positive
health behaviour, and increasing knowledge and
dissemination of information (Nutbeam, n.d.,
p. 5).
Several themes and ideas are worth highlighting
from both the Charter and the earlier Concept
and Principles Document: involvement and parti
cipation, action (implying change), methodo
logical pluralism, community accessibility, and
development and process (made plain by the use
of words like strengthening, promoting, increas
ing). These themes and ideas indicate a commit
ment to the alteration of the status quo. The
package is therefore dynamic rather than static, is
community oriented rather than disease oriented
and points hopefully to some future better state.
An initial difficulty in putting practical research
substance onto these worthy aims and of translat
ing these goals into action is their sheer scope.
Describing wide ranging aims and ideals does not
provide an immediately obvious research focus.
Tannahill (1985) highlights this when he outlines
some of the more obvious domains that might be
defined as health promotion. He lists six activities
(rather than goals or future states) which lay claim
to be called health promotion. TTiese are: efforts
to improve unhealthy or unhealthful behaviour;
activities designed to encourage positive health;
health education; health education in conjunction
with legal and fiscal measures to improve health
and prevent disease; the process of enabling
people to increase control over and improve their
health; and activities meant to improve the health
of individuals and communities. The question
posed by TannahilTs list is whether these dispar
ate activities should be called health promotion at
all. These activities might more accurately be
described as part of the socio-politics of public
health. In any event, whatever they are called, the
range of activities highlights the immense scope of
health promotion and therefore of its research
base. The socio-politics of public health is a vast
research agenda.
The implications of this have been widely
recognized. WHO have identified important
priority areas in their Research for Health for All
strategy (WHO, 1988a) some of which directly
underpin health promotion. It is suggested by
WHO that research should be goal oriented and
directed (i.e. it should be practical rather than
purely theoretical). In this endeavour the fact that
community participation should be a cornerstone
of this process and that communities should be

SOME PROBLEMS IN HEALTH PROMOTION RESEARCH 319
involved in the studies is underlined (WHO,
findings of considerable interest and imponance
1988a, p. 9). It is argued that research should be
to health promotion, but whether this advances
inter-sectoral, multi-disciplinary and multi
the discipline of health promotion is an open
professional. An orientation away from hospital
question. If political scientists and sociologists
based medicine towards health policy and health
can do this, is there any special need for a separate
status is stressed. Research should aim, it is
remit for health promotion research? The very
argued, at understanding the mechanisms which
important contribution which the social sciences
create and maintain health inequalities. The con
can make is widely acknowledged, in particular in
sumer’s perspective in the assessment of health
health services research (WHO, 1988b, pp. 60care needs should be a priority. Against this back
65). Unfortunately, WHO seem to pin their hope
ground and with an explicit recognition of the key
on something they call organization theory’
role of knowledge and research in the attainment
(WHO, 1988b, p. 60). At the very least thev
of the Health for All targets, the European office
ought to refer to organizational theories, and
of WHO has specified the following research
acknowledge the fact that there are widely differ
fields, viz. health policy and organizational
ent paradigms within them. It is not a unified
behaviour, inequities, community participation
mono-theoretical perspective, and as such is no
and inter-sectoral collaboration, information
substitute for health promotion developing its
systems and indicators i elated to the targets and
own research base. The distinctive nature of
international comparative studies (WHO, 1988a,
health promotion research must therefore be
p. 12).
identified (WHO, 1988c, para 2 and recom
In this section of the paper the line from the
mendations).
idealistic and programmatic nature of health
Third, while the priority areas for research
promotion, through attempts at defining practice
activity specified by WHO are useful, even in their
to the definition of priority areas for research has
own terms an awkward problem remains. WHO
been sketched. I suggest that three problems
have spent a large amount of time and effort in
remain which have a considerable impact on the
identifying research aims, priority areas and
way in which health promotion research may
targets (WHO, 1988a, pp. 8-9). These targets
develop. First, ideals and programmes for
have been vigorously debated and honed into the
improvement do not translate easily into research
overall Research for Health For All package. At
questions. Statements of intent contain, poten
the same time, community participation is held as
tially, a strong element of self-fulfilling prophecy,
the ‘cornerstone’ of the Health For All strategy
and a marked historicist bent. The is’ and the
(WHO, 1988a, p. 9). The obvious question is to
ought to be' become conflated, and the answers
what extent have communities participated in
to the research questions may become ideologic
setting such priorities. In short, the answer is that
ally predetermined. Of course, evaluation of
they have not and WHO have assumed this role
outcomes is entirely possible within the idealistic
for themselves. WHO note that ‘These pnorities
framework and targets can be set and outcomes
will be particularly interesting to people in charge
measured against them (see e.g. Bryant, 1988). It
of policy on health research at country level-1
is doubtful, however, whether this activity alone,
(WHO, 1988a, p. 1 l).The problem of‘specifying
important as it is, would expand or develop the
the criteria for setting research priorities and
knowledge base of health promotion in any
obtaining consensus on their use’ (WHO, 1988a,
fundamental way. Consequently, the impact on
p. 32) is indeed a massively difficult task if the
practice may be of limited value.
commitment to community participation is to be
Second, the definitions of health promotion
maintained: the issue is that such participation
suggest the activity covers the whole range of the
seems to have been lost in a technocratic defini
socio-politics of public health. The socio-politics
tion of research problems (Strong, 1986). It may
of public health, in common with the sociowell be the case that the areas identified by WHO
politics of anything can legitimately be studied,
are indeed the most important ones for health
and are studied by sociologists and political
promotion to research, but how these priorities
scientists. The question is whether sociologists
were established is in itself part and parcel of the
and political scientists studying public health are
socio-pohtics of public health, not a neutral valueengaging in health promotion research or are
free statement.
doing politics and sociology. They may develop
The three problems of translating ideals into

a
0

SOME PROBLEMS IN HEALTH PROMOTION RESEARCH 321
320 M.P. KELLY

research questions, of the role of social science in
health promotion, and of the setting of priorities
are taken up in the remainder of the paper.

CHANGE, DEVELOPMENT AND
IMPROVEMENT
The ideas of change, development and improve
ment are central to health promotion. In this part
of the paper the political and scientific questions
which surround change, development and
improvement, from a social and behavioural
viewpoint are assessed. It is argued that important
theoretical developments need to be undertaken
before these ideals can be incorporated into a
research programme. The conflation of is' and
nught to be' statements must be disentangled
before research questions can be defined prec.sely.
Change, development and improvement are
hardly new ideas as far as public health is con
cerned. The sanitary movement and the practice
of public health have always carried both a
normative and a prescriptive freight. A trenchant
contemporary version of this view appears in a
widely used community medicine textbook:

Many of the triumphs of public health in the past
-elating to infectious diseases have been brought about
bv primary prevention. Similar victories over those
modem maladies, the chronic, degenerative diseases
seems, however, far from grasp. Knowledge of causal
mechanisms, whilst incomplete when set alongside the
mode of spread of an infectious disease, is adequate to
allow some action toward primary prevention in many
cases. Yet the strategies of preventive medicine do not
seem to have come to grips with the sorts of behavioural
and societal manipulations necessary to allow these
conquests to be made'. (My emphasis.) (Donaldson and
Donaldson, 1983, p. 130)
The significance of this remark lies in the authors’
assumptions first that such changes are possible
on the basis of current knowledge and that such
changes are desirable. Donaldson and Donaldson
here articulate an axiom of public health. The
axiom is derived from practice with the infectious
diseases and represents the medical model of
intervention par excellence. Isolate the agent, the
route of transmission or the action in a host and
act accordingly. They apply the same axiom to
behaviour and life style related diseases.
Although expressed by the Donaldsons within an
obviously medical paradigm, arguably the same

axiom underpins health promotion. The differ
ence is that it is not usually expressed by health
promoters in the unfashionable language of
manipulation. The ideals, the themes both of the
Ottawa Charter (WHO, 1986) and the Concepts
and Principles Document (Nutbeam, n.d.)
demonstrate the same commitment to change, but
stripped of the overt interventionism of the public
health medical model. The HFA Targets are
oriented in the same way and the related Healthy
Cities programme is tied into the same axiom. As
WHO argue:

The deepest motive for studying current life styles is (he
intention to change them, to promote life styles that
enhance health and to reduce those that damage it.’
(WHO. 1988a, p. 24)

These quotations suggest that the interventions
against the infectious diseases worked. The
implication is that a similar kind of intervention
on behaviour or social structures will also work.
The problem is whether the medical model of
intervention against infection is appropriate for
interventions called health promotion. In general
terms it is not. There are two rather separate
reasons why this is so: normative and scientific.
The Donaldsons and WHO share a normative
stance. It is normative because it assumes that
health is better than illness and that pathology is
undesirable. Therefore, intervention is justifiable.
On the face of it, this is a not unreasonable,
perhaps even self-evidently true, argument. For
example, in terms of a comparison of morbidity
and mortality from infectious diseases in Britain
in the nineteenth century and in 1980, it would
appear to be valid. The contemporary carnage
wreaked on the population of a country like
Scotland by lung cancer and cardiovascular
disease bear eloquent testament to both the
evident truth of the proposition and to the
urgency of the intervention task.
It is, however, worthwhile reminding ourselves
of several things. Quite apart from the widely
acknowledged danger of‘healthism’ (establishing
an ideal of a healthy fully integrated and psycho
logically well balanced person as a social norm;
WHO. 1988b, p. H7) other factors may be
operating. It has long been observed by clinicians
and lately discovered by sociologists that the
advantages attaching to the sick role, such as
being relieved of normal social role respons
ibilities, and not being held responsible for the
sickness condition, might not only be ‘enjoyed' by

evaluative because the benefit of the intervention
the occupants of the sick role when they are ill, but
has to be weighed against its cost. It is philo
might be actively sought out by people who are
sophical in that the right to intervene on others, or
not diseased. The secondary gains of the sick role
their housing conditions is a political position
may, in certain circumstances, make it a desirable
deriving from the high value placed on health as
state in itself. Being ‘ill’ is a mode of adaptation to
opposed to illness. It is not a scientific principle. It
a social as well as a microbiological circumstance,
is a political position, although perhaps not easily
and from a lay perspective being ill may not be
defined in terms of party politics. Intervention
viewed as a bad thing at all (Parsons, 1951).
might, for example, be authoritarian, paternalistic
Second, the assumption that a priori health is
or humane; non-intervention might be free
good is challengeable on the grounds that the
market laissez-faire or libertarian. The questions
positive value placed on health and concomitant
are what ‘rights’ do people have not to be inter
well-being, and the negative value placed on
vened on? What rights do people have to ruin
health damaging behaviours by medical science is
their lives with self-destructive conduct? What
not universally shared by the population at large.
rights do people enjoy whose lives are ruined by
Indeed, states of extreme intoxication, and risk
destructive and noxious housing, working condi
taking behaviour, seem to contribute to a positive
tions, organisms or social systems?
sense of well-being for a significant proportion of
These are ‘ought’ types of questions. Presently
the population (see, eg. Hunt and McCleod,
they are answered mainly ideologically, politically
1987). Compound this ’lay’ conception of health
or personally. Surely this is an area of such
and illness with the problems of diagnosis,
importance to health promotion that a scientific
particularly the notion of caseness and the fact
or at least a scientifically based answer to some of
that diagnostic categories change over time, then
these questions might be attempted. RAlh^UQa simple notion that health is ‘good’ and what
sadsfactorily WHO while recognizing what they
health is, is widely understood, looks distinctly
call the ethical problems of changing behaviour,
tarnished (Wing et al., 1981). At the very least, it
answer the ethical problems with reference to
is a value position.
participation of communities in decisions that
This is not to argue for some naively construc
affect them (WHO, 1988a, p. 25). For reasons
tionist view of disease. Disease causes pain and
that will be argued below, this does not in fact
suffering, some of which is technically prevent
answer the question at all; it simply raises another
able. Neither is it to suggest that ‘lay’ conceptions
problem.
of health and illness are superior to scientific ones
These are not new concerns for the canng
(although some statements about health promo
professions.
Medicine and the social services
tion seem to come quite close to this position). It is
have had to develop answers to these types of
to argue that if health promotion is to develop a
questions as part and parcel of practice. Medi
serious research base, one of its first tasks is to
cine’s way of dealing with the question was
examine its own normative and prescriptive
professionalism—an
occupational
strategy
axioms and to develop research strategies aimed
admittedly—rather than a scientific one. I am not
at unravelling scientific and lay values. In this
suggesting that health promotion should devise or
respect WHO’s stress on the importance of the
attempt similar occupational strategies of profes
concept of positive health, and the insistence on
sionalism. I am arguing, though, that value ques
the development of appropriate indicators, is an
tions and the political cutting edge of health
important start. However, what may be required
promotion are research questions or areas in
may be something more fundamental, a paradigm
themselves and could, with profit, be studied.
shift away from a pathogenic orientation alto
Turning now to the scientific question which is
gether. I return to this theme in the conclusion.
subsumed in the previous discussion, that is about
There are other research issues here too. The
the desirability of social change. Implicit y and
idea that doing something is better than not doing
explicitly, health promotion concerns itself with
something, that intervening on or with people, or
processes of change individually and/or socially.
on or at social structures carries a benefit, is itself
The idea of changing behaviour, life styles and
a researchable question. It is researcheable in the
attitudes is an integral part of the package. Yet the
micro-contexts of individual projects, and in a
impact of theories of social and behavioural
more general sense. It is researchable both in an
change on health promotion has been limited.
evaluative and philosophical value sense. It is

(D

322 M.P. KELLY

Allison et al. (1988) found in their extensive
tion of personal rather than group advantage.
literature review that the social sciences had had
Social psychologists have provided enormous
little or no impact theoretically or methodo
evidence about in-group and out-group pro
logically on health promotion. The extensive
cesses, about prejudice and stereotyping, all of
discussions in sociology and psychology of
which are germane to any group interaction. The
change and development do not inform practice,
point is not that there are a multitude of per
or at least writing about practice, to a very
spectives but that the rhetoric of participation
significant degree. Allison era/. (1988) made the^ conceals a very large theoretical baggage which
|oint that the health promotion literature isB can inform an understanding of the participative
largely exhortative ... prescriptive rather than 3 process.
Bnpirical in nature ... not for the most part
In summary, the formulation of research ques
Beoretically grounded’.
tions in health promotion may be problematic
”This must be counted a serious weakness. The
given the prescriptive nature of the ideals of
detailed analysis of particular health promotion
health promotion. The potential danger of ‘is’
Initiatives from a developmental or social change
translating into ‘ought to be’ and muddying the
perspective must be regarded as a high priority in
clear definition of the problem is important. The
health promotion research. This is not to mean
ought to be’ of health promotion carries with it a
that more time should be spent on process rather
range of normative assumptions which as a first
•han outcome evaluations. It is to highlight instead
step in the research exercise must be made plain
;hc fact that an evaluation must make explicit the
and, indeed, can form research problems in them
models of social or behavioural change which (i)
selves. The ought to be’ is not juit political and
are thought to be operating (i.e. formed part of the
ideological, but derives from the largely success
objectives of the study) and (ii) are actually
ful assault on the infectious diseases and of the
operating. When heajth promotion interventions
usefulness of the medical model in explaining that
are planned, it is not sufficient to argue that a
process. It is questionable whether this interven
developmental, or participative or empowerment
tionist' model is applicable to health promotion
perspective is being adopted and that evaluation
even when stripped of its medical origins and re
•vill be carried out. The model or the mechanism
dressed in the language of democratic account
of social or behavioural change which is implied
ability. As far as the ‘is’ questions are concerned,
must be made plain at the outset, otherwise it
at least one authoritative source suggests that
cannot be evaluated adequately.
social scientific theories, models and data which
A specific and recurrent example where some
could inform discussions and practice have had
articulation of a theory of change and develop
only a marginal effect. Even in an area as
ment would help is the issue of ‘participation’.
important to health promotion as change through
Participation is premised on equality of power
participation, the inputs from politics, sociology
relations, and a theory of the common-good and
and social psychology have been minimal. It is not
group djmamics. However, political scientists and
simply a methodological question of developing
sociologists have demonstrated in different ways
indicators which are sensitive to change as WHO
that equality of power relationships allowing
imply (WHO, 1988b, p. 114). It is a theoretical
participation is but one of a possible range of
question of understanding the process of change.
scenarios. Conflict and coercion are more usual
forms of power arrangements. Political and social
theorists have also shown that the notion of the
THE AGENCY-STRUCTURE PROBLEM
common-good emerging through group con
sensus or group dynamics is based upon a model
The theory and therefore the research baj; of
of the human actor who can imaginatively stand
health promotion, in common with all the human
outside the social structure to see the common
sciences, has to take account of the question of
good. Equally, that some human actors will see
agency and structure in human behaviour. Put
only personal advantage, and act out of spite and
simply, is human behaviour the consequence of
venality when they imaginatively stand outside
people making free choices (agency) or is human
the social structure is a well-worn theme in
behaviour an outcome of the world (structure)
political science. The discipline of economics
around them? Social and behavioural theorists
underwrites in the theory of utility the maximizahave long debated whether the species is the agent

SOME PROBLEMS IN HEALTH PROMOTION RESEARCH 323

of its own destiny whom through purposeful activ
ity and action shapes the environment in which it
lives, or, whether humans are but the victims of the
social world they inhabit in so far as their actions
and activities are determined by thesocial environ
ment in which they find themselves. The dialectic
between agency and structure is a very profitable
source of understanding human conduct.
In the context of health promotion, the ideas of
empowerment, enablement and healthy public
policy straddle the tension between agency and
structure as is widely recognized (WHO, 1988b,
p. 112). Consequently, any definition of research
questions around these areas must take account
of the agency-structure problem. To fail to do so
will make the formulation of specific research
questions very difficult. For example, in a general
sense, there is nothing so liberating as the ability
to do something. The power to act upon one’s
own environment and to shape it in a way which is
congruent with one’s conceptions, is giving free
range to human agency (Kelly and Glover, 1988).
Such human agency and liberation is based on
skill possession. Community development and
health promotion programmes sometimes take as
a core objective, the development of the liberating
skills which will facilitate empowerment.
The theoretical paradox is that at the same time
the very presence of a community development or
health promotion programme in the first place,
suggests that a definition has been made by
someone (funding agencies, local government,
health agencies) that a community has special
problems which are themselves defined in struc
tural rather than human agency terms (typically in
terms of multiple deprivation, unemployment and
so on). Thus the raison d'etre of the project may,
theoretically speaking, be at odds with its liberat
ing aims and objectives. The study of such
tensions is important, not as an exercise in resolv
ing the theoretical agency-structure problem, but
as a means of throwing light upon questions of
‘top down' as against ‘bottom up', upon issues of
definitions of need and provision of services,
upon issues of demand for and organization of
care. Put bluntly, the degree to which local com
munities can, or are allowed to become involved,
to participate, is notf a matter of principle, its
practical application and its facilitation are scien
tific matters deriving from the agency-structure
problem. Health promotion research must
develop ways of dealing with and understanding
these things.

These are of paramount importance if em
powerment and enablement based initiatives are
not displaced by organizational forms that deny
power and de-skill. Kickbusch (1987, p. 439)
argues that ‘communities need support networks
that encourage people to take more control’. The
agency-structure problem is germane because
what Kickbusch and the whole thrust of health
promotion have in mind is control gained through
the participative actions of local communities
(making locals the agents of their own destiny).
The danger is that in all organizations, structures
emerge which can displace human agency.
Power-to-the-people may mean that powerful
groups emerge to exercise power for the people.
The list of possible candidates for seizing power
in this way is a long one: it includes bureaucratic
health administrators; non-medical health profes
sionals (health educators, promotors, health
visitors); community activists; political parties;
habitual joiners or even health promotion
researchers. The issue is that while the goals and
aims of health promotion stress the liberating
nature of human agency, the social structural
forces which can so easily swamp this, present a
powerful negative structural force. Although
intended to be benign and indeed intended to
eliminate the worst effects of negative structural
forces, such as bad housing, poverty and un
employment, the nature of the dynamic interplay
may make the benign structures just as much a
part of the problem for the community as the
negative forces they were set up to improve.
These kinds of problems must be seriously
addressed in research terms, an issue which is
recognized by WHO (WHO, 1988b, p. 69).
Another context in which agency and structure
must be researched is in the context of healthy
public policy. Kickbusch (1987) writes about
healthy public policy and about making healthier
choices the easier choices for people (Kickbusch,
1987, p. 438). She thus addresses the agency
structure problem directly. The idea of making
healthier choices easier under healthy public
policy contains a recognition both that human
actions are purposeful, i.e. people make choices;
and that choices take place within a social struc
ture which constrains, limits and determines the
available choice. Healthy public policy provides a
legislative and economic framework within which
‘healthy choices’ may be made.
This framework then has to be translated into
practice. Arguably translating it into practice

CD
CH

- i

1

324 M P. KELLY
must be preceded logically, by identify

’Is the stimuli supposed to act like a conditioning
Che list of social scientific models could be
device? If so, are we talking about operant or
expanded almost indefinitely. The link with health
classical conditioning, or are we focusing on
promotion is this. Health promotion uses mode s
reinforcement alone? Is the stimuli a resource to
of human conduct to execute ns
Lnnw memberrof the public in receipt of it to
implicitly, Frequently,
rrequcnuy, hu
uuiaw
usually implicitly.
"^ «—.
evaluate the costs and benefits of reducing fat in
is acknowledged by practitioners^^t?
Is it an artefact which requires interpractitioners as complex and
compUcated.
p'X in order to give it meanmg? If so. what is
complicated. This acknowledgement is m fact
rhetoric and is common-sense. Only the most
die meaning that is developed? Is the= stimuli
die-hard behaviourist and
and the occasional
supposed to have a message which is diffused in
politician does not know that human behaviour
some way, say via social networks? Is the stimulus
iT complicated. To acknowledge complexity
a tool, which the recipient can use to shape his or
however is not an explanation: when used as
her own destiny? Writers of such media may, with
rhetoric it is retreat from explanation. Model
some justification, respond to these points by
building and theory building frequently do
arguing that the aims and objectives are always
involve simplifying reality, sometimes grossly so.
articulated in any half decent health promotion
The value of simplification is heuristic not
campaign, and that any given piece of media> may
destructive. Health promotion practice rnust not
work in all these ways. My argument is that a
shy away from the simple modelsjust because
much greater focus on the model or models
they are simple in the mistaken bebef hat by
should form a part of the evaluation, design and
strwsing the complexity of human behaviour one
overall research process.
is saying something profound. So long as the
In summary, what models of agenc) and struc
model of human behaviour is recognized as a
ture. behaviour change, political participation
model rather than a description of realny, there
and representation are implied in the practice of
is no good reason for not using models to aid
health promotion? Are such models appropnate
or desirable? How do they influence the form of
UnThislhnot to argue that models have not been
practice? What are the tensions between particu
develooed (see e g. Lefebvre and Flora. 1988
lar models? How can social science inform the
Hunt and Martin, 1988). nor that they have no
use of models in practice and researc
been used in a sophisticated fashion. Equally, it
would be churlish to ignore the enormous in
fluence of the Health Belief Model and Locus o
Control Theory. However, ^e general argumen
that models and theories have had limited impact
logically precede the concept and
„d that new distinctive health promotton models
^-^00.
guidede
J r
. •
, ouidedebybv
and paradigms are required, remains.
adeauate theory and if theory is not articulated, it
To take a concrete example. Ifonc ProduJacts?
?d
t t0 impossible to engage in any kind of
piece of media-say a leaflet about
o^rationaliza^on or measurement of variables,
diet—there are several ways in which t co
atcd|y |ays strcss On the developevaluated. Market research could be undertaken
The
pe
J
1988a| p ,7;
and the public could be asked what they
0^1
1988b p. 7 5) and much of the thrust ofthe
of the leaflet. A base line survey coul I NHaken
WHO, 19«»b. P
for exainp|e has been
and an estimate made at some time later
concerned with developing indicators. However,
people had changed/cou d remember, anythmg
rPequire adequate theory,
ibout fat in their diet/the leaflet. The argument,,
adequate tnd
4
or
that neither activity is very helpfulunul senous
hdteator^mo
prescription (who,
discussion about the nature of the
.
,988b op 38-39) are not a substitute for theory
human conduct which appears tn the leaf! .or ts
1988W8
expressed m a spunous
in the minds of the people who designed it, have
even ougn meysuremcnt There is some evidbeen discussed. Without such‘
eSa, this is acknowledged by some elements
Te^oMXnerydifficult.ThTw
within WHO
WHO (WHO,
(WHO, 1988c).
1988c).

of public health must not be shied away from. It is
an area of legitimate researchinterest andI the poL
ideal tensions and contradictions should be
widely discussed. This will involve working
closely with political and administrative

nrocesses, and about whose definitions will be
used to define health. This quesuon reflects
discussion in
an earuci
earlier
discussion
m an
,t-r - .
how? and the who? and the •what?
what, off heaJ“1'"
choices must form an integral part of any research

uw,ullls.„.--------------would be/decontextualized
and emasculated,
Because 'the'practice
of health
health promotion
promotion isis
Because
the practice of
ld ”fM
{ removed
amoved from poUncs
politics, ^liticsia
politics is and
seldom
research

agtadJteoretical terms, health promotion as a
principle and as an activity stands at the ‘n'erface
of structural forces and hun{"?
tension.

_^multiplicity of models in
, may, however, cause problems. This can be
illustratedwnn
withreiercnvc
referenceavto«a particular c^Pl
illustratea
•

•jim;’fwV"pa°rticSuH To ffi^omotion

importance of the promotion

research questions in this way !nvol*«;ePr^X
next section, the question of models is constdered.
THE QUESTION OF MODELS OR
PARADIGMS

"SPSS'S
(structural/individual;
pie) different paradigms of explanation ™

P
by this principle, vir how
do coping strategies and dispositions relate to
beliefs" and life experience? and what is flic
nature of the inter-relationship? To indicate that
these things are related together in some way is
ihe start of the scientific endeavour, not an
explanation in itself, nor is it a theoretical or
SC^ waylSis to think in terms of models
of human behaviour. Economics. P^chotogy and
sociology have developed vanous models of
socl
..fhich USefully guide social scien-

the creature possessed of an' economic calculus,
■weighing up decisions, estimating costs and ben» . B .
etitSOI
acuon Ui a_«___ ...i*^n*ahl»anrilcHncalfash------ —
ion There are numerous versions of Homo
humam tend to make political statements, albe.t
psychologic- In one, the human is an animal qua
responding
external sttmuh
sometimes obliquely. There >s nc£nmial
‘
u„, to rparticular
.._
wavs which are mediated by mechanise
mecharosms^of
so long as the competing
Yfre' hHs
in ways
(mabily^re the*bearers of conscious or ui
the bearers of conscious or uncon, instincts and motives directing

- .sar=« =as

edgement of diversity and cottfronung

and encouraging thetr development
gives it a political cutting edge. The soao-pohti

render responses to the leaflet meaningful is by
modelling the response to the stimuli in advance.

worker (Berger, 1964).

I
i

CD
CD

Ii
326 M.P. KELLY

THE ROLE OF RESEARCH
The Concepts and Principles document states:

Research support is essential for policy development
md evaluation to provide an understanding of influ
ences on health and their development, as well as an
assessment of the impact of different initiatives in health
promotion. There is a need to develop methodologies
for research and analysis, in particular, to devise more
appropriate approaches to evaluation. The results of
research should be disseminated widely and com
parisons made within and between nations’. (My
emphasis.) (Nutbeam, n d. p. 7)
Target 32 states in related vein: ‘Before 1990,
all Member Slates should have formulated
research strategics to stimulate investigations
which improve the application and expansion of
knowledge needed to support their health for all
developments’. (My emphasis.) The stress on a
support role for research is probably misguided.
Research has a much more important role than
being merely supportive and has much more to
offer than being a way of refining evaluative
methodologies, although it can accomplish these
tasks very well.
Nutbeam’s statement is located in an AngloSaxon culture-bound view of the distinction
between pure research on the one hand and its
application on the other. The assumption which I
wish to question is that of the distinction or
division of labour between researchers and scien
tists, on the one hand, and practitioners on the
other. According to the assumption the former
tend to work in universities or prestigious
research institutions and deal in the highly prized
currency of the fundamental questions of pure
knowledge. The latter, the practitioners (more
worldly individuals with more practical down to
earth concerns) and their brethren who teach
practice in polytechnics and colleges, engage in
applied work. This is a particularly Angl^Saxon
distinction (Kelly and Glover, 1987). Such a
distinction may accurately reflect the state of
affairs that exists in the United Kingdom, but that
makes it neither natural nor right.
In contrast in German culture where the
division between pure knowledge and applied
knowledge is not made in the same kind of way,
for example, activities like engineering which in
Britain might be thought of as applied
occupy a separate and prestipous ground called
Technik. In essence Technik means the amal-

gamation of theory with practice in a knowledge
able and workably useful way, stressing the
making and using of artefacts and tools. Health \
promotion, allowing for a semantic differential, is I
m essence a Technik activity, or at least it should j
be. It is action oriented. It is about interventions f:
that have, workable effects, for reasons that ’
should be understandable both from practi-1
tioners’ and community’s viewpoints. Arguing!
Stat research should have only or merely a;
supportive role in health promotion, not only!
sirves health promotion of a major asset and the ;
theoretical sophistication that goes with it, it •’
reproduces a particularly Anglo-Saxon version of
elitism based on the superiority of knowledge as
again*! practice. It is hardly any wonder that
important theoretical research ideas have had
little or no impact on practice: they come from an
alien and elitist culture, al least in the British
context.
However, the question of a role for research
vis-d-vis practice goes deeper than culture-bound
Britishness. Staying with the analogy of Technik,
if an engineer constructs something and it fails to
work, or more likely it fails to work as well as it
should, lay people have an immediate and
obvious criteria by which to judge the object in
common sense terms. It is either useful or useless.
Public evaluation is the final arbiter. What criteria
do lay people have to judge interventionist
strategies like health promotion? As Johnson
(1972) has argued, in the case of medicine, at least
the lay public has certain minimal guarantees
against gross incompetence in the form of profes
sional control, whatever other self-serving func
tions medical professionalism might involve. In
the case of health promotion the lay public have
neither the guarantees nor even the necessary
access to nor means of evaluating what might be
done for them or on their behalf. This is poten
tially a significant irony, because while on the one
hand health promotion is dedicated to commun
ity involvement, some of the practice and poten
tially much of the research has to be taken on trust
or on the basis of ideological convergence.
This, as was argued above, is of critical import
ance. There is a very real danger of WHO falting
on it* own sword. Community participation is a
comentone of Health for All. How this meshes
with bureaucratically defined and state imposed
priorities and targets is an important, and barely
acknowledged problem in WHO publications on
the subject (WHO, 1988a, for example (but see

SOME PROBLEMS IN HEALTH PROMOTION RESEARCH 327

also the more sensitive statement in WHO,
1988b, p. 117)]. The principal agents for the
setting of the research agenda are defined as ‘the
highest authorities in each country’ and ‘scientific
groups and professional associations' (WHO,
1988a, p. 34). The role of those disciplines which
are inherently critical and questioning rather than
prescriptive in orientation does still not appear to
have made its mark on official WHO thinking, as
Strong (1986) commented on some time ago.
It might be argued that trust based upon the
canons of scientific rigour should be sufficient.
Quite apart from the fact that over the years a
great many scientists have been critically
mistaken about a whole lot of things and lay
people place their trust in scientists at their peril,
more importantly, the practical problems of
opening up dialogue between researchers and
those on whom, about whom and for whom the
research is being done, is a topic worthy of
investigation. There is a danger that an activity
which is resolutely confined to academe (like
most research) becomes oriented solely to its
research audience via the pursuit of truth. (Or
more cynically if accurately, oriented to the
development of academic careers.) An illustra
tive, but by no means only example, of this
process was the so-called radical sociology of the
1960s and 1970s. Sociology was at one time pre
occupied with issues of liberation and empower
ment. The irony was that the ‘workers’ and other
groups it was aimed at, or on whom it was done,
seem to have gained little from it. Instead, some
sociology eventually found a resting place as
Organizational Behaviour in Business Studies
courses, Management Courses and so on. It
became transmuted from liberation to an instru
ment of control. For this reason WHO's point
that research findings must be placed before the
public in a clear and useful form is most import
ant (WHO, 1988a, p. 39).
There is another important related issue about
the role of research. WHO clearly holds a
developmental model of research in which policy
and practice are research driven. (WHO, 1988a,
pp. viii, 1, 19; WHO, 1988b, p. ix; WHO, 1988c,
para 1.) Indeed, the whole thrust of Health for All
is premised on the notion that in some sense
research will precede action (WHO, 1988a,
p. 19). (See Glover and Kelly, 1987, for a critique
of this view.) The idea is that if the research is
done, new knowledge is produced and then the
result will be changed practice. The problems

with this are first, that it ignores the fact that
knowledge including scientific knowledge, may
be socially constructed and socially grounded;
second, that scientific facts and theories rarely
have this kind of impact in any field—new ideas—
even those which come later to be regarded as
correct frequently find great difficulty in gaining
initial acceptance (Kuhn, 1971); third, it main
tains an artificial distinction between knowledge
and action. Next, the whole issue of the way
knowledge is dispersed or diffused is overlooked
or delegated to state or supra-national agencies.
Sociological data about the way science networks
are developed arc ignored. Above all, it implies a
rational model of policy making which in turn is
premised on a rational model of decision making
which is only partially valid. Decisions are
reached in bureaucracies, but whether they ar<
reached on the basis of the availability of the best
information is highly doubtful (cf. Mintzberg,
1973). The corporatist model of policy formation
set out in Target 36, for example, simply does not
stand up to close comparative-historical analysis
(WHO, 1988b, p.43).
Whither health promotion research? Unless it
ties itself firmly to practice, the same forces may
come into operation and those most in need,
those most at risk, those whose lives cry out for
assistance will become lost from view. Health
promotion research must embrace practice, but it
must eschew any simple customer-contractor
view of research wherein a customer fWHO, the
state) establishes a set of priorities, aims or goals
for research and a contractor executes the
research (Rothschild, 1971). There is a danger
that HFA targets might be used in this way to set a
research agenda. Under such a system, the prob
lems of doing research become strategic (finding
the most efficient, cheap or quick way of getting at
the target question) and tactical ones of executing
it. The concerns are neither theoretical nor
methodological in anything other than a technical
sense.
Concerns about who defines the research
problem, why particular issues come to be
defined as research problems, and why they are to
be investigated in particular kinds of ways must
not be assumed a priori or taken as self-evident.
The underlying assumptions should be subject to
critical assessment. The issues of: who should
define problems worthy of action and research?
(medicine? government? civil society? pressure
groups? community? WHO? Who?); what should

CD

dH

328 M.P.KELLf
constitute a research problem and how should it
be investigated? To what uses should the data be
put? and who should have access to the data?
must all be aired. And they must be aired not only
as ought’ type of questions reflecting value judge
ments and political preferences. A sound
research base may be able to help in an informed
decision-making process about priority setting.
The ways of reconciling and highlighting the
political arguments between those who wish to
define a research agenda in medical/epidemiological terms, those who wish to define it in terms
of some concept which is user defined (need/
demand) and those which are administratively
defined (organizations, management and fund
ing) need to be explored.
In summary, health promotion must consider
why particular problems come to be defined as
worthy of research; once so defined what role is
research supposed to play in health promotion
practice? Is it about evaluation, is its role support
ive, or is its role part of practice?
CONCLUSION

This paper concludes with a suggestion for a new
or perhaps a slightly different paradigm. There
are two reasons for developing this. First, as was
argued above, the question of change-for-thebetter implied in health promotion is a normative
one. It implies a future better state. Second, the
idea of positive health and health beliefs, alluded
to above are locked in a pathogenic paradigm.
The work of Antonovsky in particular offers
some interesting ideas linking together both these
identified problems.
The idea of change-for-the-better is premised
on what some would regard as unwarranted
assumptions of homeostasis. That is the human
animal is pictured as presently engaged in struggle
with a hazardous environment. The species is
gradually winning, first through the conquests we
call civilization, then the conquests of infectious
diseases and now through health promotion.
Implied is a future state in which the struggle will
be over and mankind will reach a state of healthy
equilibrium or homeostasis.
There is a clear chiliastic almost redemptionist
message here having analogues in political
theories as diverse as More's Utopia, Hegel’s
Prussian state, Marx’s socialism, or even Mrs
Thatcher's vision of free enterprise in Britain. As

SOME PROBLEMS IN HEALTH PROMOTION RESEARCH 329
most political activists come to realize, and as
authorities such as Dubos (1980), Haan (1977),
Lazarus (1976) and Antonovsky (1987) have all
cogently argued in different ways, the idea of a
future state of homeostatic equilibrium is false.
This is because it is premised on a misconception
of human life. The human condition is, they argue,
inevitably a process of ongoing struggle against
the environment at the individual, societal and
species level. To lose sight of this aspect of human
existence is to misconceive it fundamentally.
Human life is a process ‘of becoming' rather than
of achieving targets and thus attaining a higher
state of being.
Health promotion has become, or is locked
into, change-for-the-better as its idealistic and
programmatic nature demonstrates very clearly.
It is not that future better states are wrong so
much as they are misguided so long as it is
assumed that humanity will be fundamentally
changed by achieving such targets. Humanity and
individual lives are processes of becoming. Health
promotion must face up to the scientific and the
theoretical consequences of this. In practice,
practitioners have to live with this reality all the
time. Hard end points are reifications rather than
meaningful categories. Research for health pro
motion should embrace this.
Second, on a slightly different but related tack,
there has been much discussion of the concept of
positive health or positively healthy behaviour or
positively healthy attitudes in the context of
health promotion. WHO has made some move
ment towards encouraging research in the field of
positive health. We do not possess an adequate
intellectual apparatus to move towards positive
health conceptually or operationally, and it is
perhaps woiirtn while considering why this might
be so.
The reason rests in what Antonovsky (1987)
has called the pathogenic orientation of both the
behavioural and health sciences. In this respect,
health promotion is little different from medical
sociology or medical psychology, indeed, of
medicine or public health. That is to say, it is
irrevocably wedded to a notion of disease rather
than health. In other words, the conceptual model
informing nearly everything in this field is a search
for the causes of ill health and disease and
encouraging ways or means of ameliorating,
alleviating, preventing or curing the pathology.
The raison d'itre is pathology. The most wellknown and highly articulated version of this is the

I

familiar medical model of disease. Although
behavioural health scientists frequently affect a
critique of this, by and large a vast amount of
behavioural medical science works within the
same tradition—the pathogenic tradition. Per
haps it does not focus upon disease or micro
organisms ciusing disease per se and instead
highlights sti ictural, psychological, interactive or
social factors as the critical ones in pathology, but
to all intents and purposes the causal chain is the
same. The idea that bad outcomes must have bad
precursors is a given’ which has assumed the
status of the taken-for-granted. To challenge it is
to risk being seen as mad or bad because the
enterprise is about identifying, eliminating, allevi
ating or preventing those structural, social
psychological, or physiological, or biological
factors which cause, or which make people
vulnerable to ill health.
The opposite of the pathogenic approach is the
salutogenic approach, which argues that misery,
pain, illness and pathology is the normal lot of the
human being. Normal human life is difficult, is
problematic, and this is true whether you are
middle class, working class, rich, poor, young or
old. The critical question is how it is that certain
individuals and certain groups, certain house
holds and certain societies are better able to with
stand the endemic pathological onslaught of lousy
social conditions, of noxious environmental
hazards, of self-destructive behaviour, or of
micro-organisms, while others are not. The focus,
in other words, is on survival and on adjustment.
It is not a focus upon organizational or organismic
collapse: it is a focus upon organizational, social,
structural and individual survival. There are
strong ecological and Darwinian overtones to this
approach, but it does raise some interesting
questions for health promotion. It seeks to pro
mote positive health by understanding those
things which cause positive health or which
enable positive health to flourish, rather than seek
to understand those factors which cause negative
health. A salutogenic approach, in fact, raises two
distinct types of question, viz. what are the factors
which sustain health in the face of environmental/
biological onslaught and what are the factors
leading to vulnerability? The types of factors
implicated do not have to be the same nor the
inverse of each other, they could be logically and
causally unconnected. Equally, the questions
might well be asked of different populations, or
the same populations at different times. The fact is

that mono-causal or mono-factoral explanations
are extremely unlikely and instead research will
have to be conducted at a range of levels of
analysis from the organism to society. It is clearly
a major task but one which must be undertaken if
we are to get at a firm research base for health
promotion.
Antonovsky, the proponent of salutogenesis,
would not clfiim that focusing on positive health,
or the salutogenic approach, requires no know
ledge of pathogenic processes. Far from it. How
ever, if the task is health promotion, and the
research agenda is health promotion, the saluto
genic orientation might be a much better way of
moving towards a conceptually coherent frame
work rather than the mishmash of top-down,
bottom-up organizational development and a
whole host of other frameworks wtuch are at best
partial and, at worst, a positively misleading
background to the subject. Certainly WHO ha\e
emphasized the potential importance of new
approaches:
The emphasis on positive health is a promising new
approach to improving peoples health. It implies a
fundamental change of direction for health research: a
shift from the study of disease and treatment to the
study of health and the factors that promote it. A clearer
concept of positive health is urgently needed’. (WHO
1988a, p. 24)

The question is whether the implications of this
can really be carried through in the way this paper
has implied, and in a way that docs not rubbish the
medical model nor goes for the extreme versions
of the social determinism of illness. It is my belief
that a salutogenic type of approach might be the
answer. This is not to deny the real importance of
acute medicine. At times, WHO seem to come
close to equating acute intervention with high
technology medicine (WHO, 1988b, pp. 43, 48)
and contrast it with a low tech primary care
approach. It seems facile to say it, but micro
organisms and trauma and organismic collapse
will continue even if the HFA targets are
achieved. The false dichotomy of the medical
model (bad) and a social model (good) must be
abandoned in favour of a recognition of the
importance of medicine and, in particular, of
acute intervention. At the same time, the develop
ment of a distinctive paradigm appropriate to
social models of health can take place in ways in
which health promotion can be practically
researched and practiced. If this is what WHO

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317
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Health Bulletin 48/4 July 1990

Health Bulletin 48/4 July 1990

The World Health Organisation’s Definition of Health
Promotion: Three Problems

The three problems
While the WHO definition and its practical implications are extremely interesting, a
number of matters should not go unchallenged. The first concerns the alleged difference
between medical and social models of health and illness upon which it is based.

Michael P Kelly
Senior Lecturer in Health Promotion
Department of Public Health
University of Glasgow
2 Lilybank Gardens
Glasgow G12 8RZ

Introduction
This paper highlights three problems with the definition of Health Promotion which has
been advanced by the World Health Organisation (WHO). These are: a tendency to
oppose medical and social explanations of illness, a focus on the future rather than on
the present and a failure to take account of known processes of behavioural change. The
WHO definition is not necessarily the best, or the only definition of Health Promotion.
However it is influential through its association with major programmes such as Health
For All 2000 and the Healthy Cities Project. Therefore in view of its potential impact
on current planning, the internal contradictions of the definition merit attention.

The 1986 WHO Charter for Health Promotion (The Ottawa Charter)1 defines Health
Promotion as ’the process of enabling people to increase control over and improve their
health’. This process requires for its implementation a number of major political, social
and economic pre-requisites. These are identified by WHO as peace, shelter, adequate
education, basic nutrition, sufficient income, a stable material environment, sustainable
resources, social justice and equity. It is argued that a social system without this basis
is a very difficult one in which to promote health. The Charter specifies five basic activities
of Health Promotion as a consequence of the definition:

1. building healthy public policy,

2. creating supportive environments,
3. strengthening community action,
4. developing personal skills, and

5. reorienting health services to their users.
This approach to Health Promotion is based on a social model of illness and health.
Therefore it largely avoids explanations of disease which are centred on individuals, in
favour of interventions aimed at the social and environmental forces which have negative
effects on people's lives. The programme set by the Ottawa Charter is universal, for
it seeks to effect changes in social systems from the local to the global level. It places
major political and social issues within the orbit of medicine but sees medicine as only
part of the process of Health Promotion’.

176

Medical and social models of Illness
The WHO definition, emphasising political, economic and social factors, is derived
from the view that much modern medicine fails to meet the needs of individuals and
populations. High technology and high cost medicine are said to be of limited value in
dealing with, or preventing, the major health problems which afflict both developing
and developed societies. This is true, so the argument goes, in relation to diseases
associated with poverty and malnutrition in the Third World and to premature mortality
and degenerative diseases in advanced societies. High technology medicine is said to
encourage dependency on the medical profession, and to discharge individuals and
groups from taking responsibility from their own health. The suggested solution is to
change the emphasis in service provision from a concentration upon sick individuals,
towards appropriate forms of primary care and measures to address the social conditions
and the political and economic factors which determine patterns of health and illness.
Communities should become more active as empowered and liberated participants in
matters relating to their own health.

The danger of this approach lies not in its intent. Rather, an enthusiasm lor non-medical
explanations of disease may lead to a false and unhelpful dichotomy between the socalled medical and social models of health and illness. A convincing case can be made
that the medical and social models are in fact not very different in so far as both hold
that bad precursors lead to bad outcomes. The fact that. in the medical model. precursors
are largely of microscopic dimensions and in the social model they are defects in social
structure, and that the outcome is called disease in the medical model and social disinte
gration or deviance in the social model, should not detract from their similarities.
The concordance of the social and medical models is an idea particularly associated with
the work of Antonovsky’ 4. He argued that both the behavioural and medical science*
tend to concentrate upon disorder and abnormality. The difference between them is one
of method, not of their inherent approach. Both seek toexplain the origirisof breakdown.
whether of bodily systems or of social systems. This is acknowledged as a highly approp
riate activity for these sciences. In addition Antonovsky suggests that medical and
behavioural science should also focus on survival of systems. In the context of Health
Promotion this means that they should be applied to study of the origins of health as
well as the origins of disease.

The critical question in such an approach for Health Promotion is why certain individuals,
groups, households, communities, social classes and societies are better able than others
to withstand the onslaughts of economic exploitation, poor social conditions, noxious
environmental hazards, self-injurious conduct, virulent micro-organisms and accidents.
The debate between social and medical models becomes irrelevant, if the contributions
both can make to the study of survival as well as of system breakdown are emphasised.

177

o
o

&
Health Bulletin 48/4 July 1990
Health Bulletin 48/4 July 1990
TarfH actting

Anthropology. Marketing, and Organisational Behaviour which all study change in
particular facets of human activity, the availability of models to understand change is
enormous.

The second problem which resides in the WHO’s definition of Health Promotion is its
strong orientation towards action for change-for-the-better. The setting of goals which,
if achieved, will bring much needed improvement to the health of populations or groups
is the logical policy to follow from this orientation. For example, in the Healthy Cities
Project much effort has been expended in devising appropriate indicators to measure
future states of change. While an orientation towards the future and attempts at scientific
evaluation using indicators are understandable and laudable, there is a danger that
targets for future achievement may distract attention from present Health Promotion
needs in existing communities. For example, epidemiological arithmetic may be
employed to assign targets for the health of total populations at some remote time in
the future. By targeting a 15% reduction in a specific disease in a particular community
by the year 2000 a future improved state of affairs is identified. But people are living
in that community now. They may find survival uncertain and difficult at the moment.
They will probably continue to do so in the year 2000 or 2010 and beyond. Community
health profiles often show that ordinary people are, unsurprisingly, very concerned with
problems of living in the here and now and with problems of surviving today, tomorrow
or next week. They tend to be much less concerned with problems of dying or not dying
by the year 2000, except in the most general sense.

WHO statements make little reference to the available literature on behavioural and
social change5. This is unfortunate because if the agenda for Health Promotion is change
in a broad sense, or if particular changes are required at local level to improve the life
chances of individual communities, some reference to the models which may help in that
process would be appropriate*. Of course not everyone involved in Health Promotion can
be a polymath with respect to the breadth of the Behavioural and Social Sciences.
However, if and when a Health Promotion intervention is planned at any level_
community, local, regional, national or even global—attention should be given to the
model of social and behavioural change that will operate’. Thought needs to be given
to how an intervention will work. A clinician always knows what he or she expects from
particular actions. Processes may not be fully understood, but a framework (the real
medical model rather than the straw man frequently attacked by the social model of
health) exists to make sense of actions and to interpret results.
Social and Behavioural Scientific models have exactly the same role. The processes they
seek to describe may not be completely understood, but they do provide a useful means
of making sense of what is going on. This simple idea sometimes seems to be lost from
view in WHO statements in which Health Promotion is presented as a combination of
good intentions and ideological conviction rather than as a matter of science.

A compelling argument can be made that the practice of Health Promotion should assist
or facilitate healthy living now. rather than set targets in the anticipation, or hope, of
a better future. (This is not to say that traditional preventive medicine should not aim
to reduce premature mortality by the year 2000 or any other date, but Health Promotion
and preventive medicine should not be considered synonymous).
It can be argued that the cornerstone of such an approach to Health Promotion should
be an undemanding and development of coping processes and skills. For example, the
observation that a high rate of coronary heart disease is related to smoking may lead
to attempts to stop people smoking. An education or other type of preventive programme
may be developed. However, if the programme ignores the fact that (addiction and
pleasure aside) some people routinely cope, or think they cope, with the stressesof their
lives by using tobacco, and does not offer alternative coping skills or does not address
the origins of the stress, its chances of success are likely to be limited to those who can
And ways of dealing with stress other than by smoking. The very up*beat WHO approach
to the future and the targets, the very creditable desire to change this for the long term
good, may be the undoing of a programme if it ignores people’s present problems.

Conclusion
Health Promotion is a new. exciting and potentially very important development. But
there are difficulties with WHO's definition. If the definition is to form the basis for
practice, the three concerns of this paper need tobe addressed. Health Promotion should
not be portrayed as an exclusive alternative to medicine. It must work with medicine
towards understanding the origins of health in addition to the causes of disease. A focus
on the future should not detract from current needs. Finally, any intervention should
be adequately informed by appropriate models of change drawn from the social and
behavioural sciences.

Acknowledgements
Betevfonrai mU Mdai rhaage
The third problem with the WHO deflnition is its scant attention to the sciences of
behavioural and social change. The disciplines of Sociology, Psychology and Social
Psychology are directly concerned with the kinds of changes which the Ottawa Charter
seeks to encourage. Sociology was founded on investigations of how societies as a whole
or their component parts have developed and changed. The discipline consequently
has many models of social change. Psychology takes as one of its core elements the
development and change of the individual. Social psychology focuses on group dynamics
and change. If to these three are added the disciplines of Political Science, Education.

178

I am grateful to Graham Watt who offered many helpful criticisms of earlier drafts of
this paper. Thanks also to Norah Adams.

References

1. World Health Organisation. Ottawa. Charter for Health Promotion: an international
conference on Health Promotion—the move towsrds a New Public Health Ottawa. I9R6

2. Kickbusch I. Introduction 1-3. In. Anderson R tt al eds. Health Behaviour Research and
Health Promotion. Oxford: Oxford University Press, 1988.

3. Antonovsky A. Health stress and coping. San Francisco: Jossey Bass. 1985

179

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In

duction to Community Empowerment,
articipatory Education, and Health

Jilt

Nina Wallerstein, DrPH
Edward Bernstein, MD

■ WF'

INTRODUCTION
Why at this time do the concepts of community empowerment and participettory education merit two special issues of Health Education Quarterly? What
can we learn from groups and communities engaged in empowering health prac
tices? What are our roles as health professionals? Are we resource persons,
expert consultants, facilitators, or community organizers?
These questions are particularly relevant today, with deteriorating socioeco
nomic conditions for large segments of society, especially for the very young,
the old, and minority groups. The problems of barriers to care, lack of health
insurance, high unemployment rates, high infant mortality and homicide rates
among minorities, battered women, homelessness, escalating health care costs,
the epidemic of drug abuse, AIDS, and violence have drawn millions of people
into political life around the debate on health care reform, prevention, and
public health. Unfortunately most of these problems are not addressed by the
current health care “nonsystem," or reform plan.
Many health professionals and clinicians have defined the problems in medical
or individual life-style models. Even in community settings, the language we use
may reinforce a professionally driven solution to the problems. To our surprise,
we often hear ourselves say in our work or personal lives: “Don’t drink and
drive," “Give up those cigarettes before you get cancer," or “This community
needs to recognize that drugs and violence are killing its people."
What does it mean for one group to name the problem for another? What
evidence do we have that information or advice, or the blaming implicit in much
community and preventive work, can bring about health behavior change or
increased community empowerment?
Health care reform could create favorable conditions for collaboration, public
advocacy, political action, and community empowerment. The challenge exists
for us, as health educators, other health professionals, and medical care providers

Ki.

■
•W ■Ir I

o
Nina Wallerstein is Assistant Professor, Department of Family and Community Med
icine, University of New Mexico, Albuquerque, New Mexico.
Edward Bernstein is Associate Professor, Boston University School of Public Health,
Boston City Hospital, Boston, Massachusetts.
Address reprint requests to Nina Wallerstein, Department of Family and Community
Medicine, University of New Mexico, Albuquerque, NM 87131.

7

i

■

Health Education Quarterly, Vol. 21(2): 141-148 (Summer 1994)
© 1994 by SOPHE. Published by John Wiley & Sons, Inc.

CCC 0195-8402/94/020141-08

MSI EI

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and solutions, and how we define our mission and relationship to those with
whom we work. We must critically assess how we in
porate a respectful re
lationship with people in communities so as to facilitate their naming the prob
lems and solutions for themselves, and to create the conditions for professionals
and communities to engage in empowering practice together.

feeling, if you are not able to use your recent freedom to help others be free
by tr
orming the totality of society, then you are exercising only an individ
ualist attitude towards empowerment or freedom... While individual empow
erment, the feeling of being changed, is not enough concerning the transfor
mation of the whole society, it is absolutely necessary for the process of social
transformation6 (pp. 109-110).

COMMUNITY EMPOWERMENT AS A BASIS
FOR HEALTH REFORM

NAMING PROBLEMS, SOLUTIONS, AND ACTORS

With the term “empowerment” fast becoming a ubiquitous buzz word, health
professionals and the lay public alike need to carefully reexamine and clarify
this concept. The public health field has contributed to interest in the term, with
the recognition of powerlessness as a broad risk factor for disease, and, con
sequently, empowerment as a health-enhancing strategy.1
The popular use of empowerment has unfortunately been appropriated by
politicians and management who focus on empowering corporations by making
individual employees feel more valued, satisfied, and productive. Management
experts envision a more democratic work place where employees are empowered
to get in touch with their creativity and make decisions without being strangled
by the chain of command.4 5 Although there is a positive side to a change in
corporate culture through respect of relationships and improved job satisfaction,
powerment differs fundamentally from the con
Covey’s4 concept of personal empowerment
cepts of participatory education and community empowerment presented in
these two volumes.
The articles published here are reflective of a culture that promotes social
responsibility and social justice, rather than individual satisfaction in isolation
from one's community and society. As used throughout these two journal issues,
community empowerment is defined as a social-action process in which individ
uals and groups act to gain mastery over their lives in the context of changing
their social and political environment. This process can occur in communities
interpreted in the articles as geographic, institutional, and relational interest
based associations.
Empowerment, or community empowerment, a preferred usage because ot
the social context in which empowerment takes place, thus embodies an inter
active process of change, where institutions and communities become trans
formed as people who participate in changing them become transformed. Rather
than pitting individuals against community and overall societal needs, the com
munity empowerment construct focuses on both individual and community

Brazilian educator Paulo Freire has brought us this dialectical understanding
of individual and social empowerment, by sharing lessons learned from liberation
movements in developing countries. He advocates a participatory education
process in which people are not objects or recipients of political and educational
projects, but actors in history, able to name their problems and their solutions
to transform themselves in the process of changing oppressive circumstances.

To Freire, community empowerment starts when people listen to each other,
engage in participatory/Iiberatory dialogue, indentify their commonalities, and
construct new strategies for change. Through dialogue, we can learn from one
another’s perspective and discover new ways of looking at problems. Listening
to how society’s opinon-makers define problems and solutions illustrates both
the barriers and the possibilities for community empowerment.
The proposal for financing a portion of health care reform by legislating a
“sin tax' is a case in point. Naming the solution as a sin tax points the finger
at a stigmatized individual, “the sinner.” In this equation, the psychosocial,
economic, and cultural factors, which include racism, poverty, violence, and
social stressors are not addressed. The large multinational corporations that
profit from alcohol, drugs, tobacco, and guns, including their lobbyists, adver
tisers, and political apologists, are free to blame the consumer and to block
protective legislation. On the other hand, naming the solution a “healthy people
tax” could muster public support and participation in deciding how to allocate
the new resources towards prevention and treatment.
At the 1993 National Medical Association scientific assembly addressing the
epidemic of violence, Ronald Walters challenged the assumption that you can
treat violence the same way you treat smoking or auto safety, and advocated a
political solution that addresses root causes:

Violence is a product of social dysfunction... You begin in the black community
with a baseline of alienation that is higher than that in the white community.
We know that the withdrawal of resources has weakened the infrastructure of
our community. In the period between 1980-1990, the federal government with
drew $261 billion from direct support of inner-city communities. You add to
that the withdrawal
the tax base (caused by) individuals moving out of the
inner city, add to that the withdrawal of hundreds of thousands of jobs in the
same period and you have a scenario which says that the drug trade can walk
in, sit down, and become the industry of choice for many of our children7 (p.

In the same forum that debated how definitions drive our practice, Carl Bell
argued for an integrated public health approach: “We need surveillance to iden
tify children at risk. We need to teach conflict resolution. We need to intervene
with public health problems... As a black physician, I am going to try to reach
the black child who saw his mother get killed and convince him not to kill
somebody else. That’s where I start, and that’s where I suggest we all start. We

can really do two things at me same time, vw
and we can deal on the level of the individual”7 (p. ‘”‘’4).
Multiple definitions of community, and differences how we approach com
munity work—from social planning to social action and locality deve opment
also influence how we implement an integrated public health model. Without
community dialogue and participation in decision-making around problem de inition and solutions, policy changes—whether they are socioeconomic or spe
cific risk factor reductions—cannot contribute to community empowerment.
Ultimately, community empowerment strategies must also be linked to the larger
society to ensure policy and political solutions that decrease health and socio
economic inequities and foster healthier places to lives.

PRACTICE AND RESEARCH CHALLENGES
OF COMMUNITY EMPOWERMENT

of community empowerment and participatory/liberatory ed
The concepts
ucation present a number of challenging issues that we as health educators and
other health professionals need to address. The articles, in this two-issue set,
debate these issues, mirroring debates taking place through our society, and
present some solutions tested in practice.
.
.
The first of these challenges is how to ensure we value and honor individual
contributions, yet address, on a community and societal level, the underlying
conditions that further powerlessness. If the act of participating in community
actions promotes changes in self-worth and in the belief that condttions can be
changed by group efforts, then there may be an increase in an individual sense
of empowerment. A critical mass of individuals participating in the life of the
community may also increase community empowerment. The question remains,
therefore How does this dialectical interaction work in practice.
A second challenge is how we as health educators work effectively with others
for community empowerment. Many professionals occupy more central positions
of power or privilege than community members with whom we work (although
people on the lower rungs of bureaucracy, particularly people of color may
share powerlessness and scarcity of resources with the people they serve) This
position of dominance, whether from culture, race, gender, class, or status,
raises the question of whether a relatively privileged group can empower others
or whether people have to take power and empower themselves . If people hav
to empower themselves, then what is our role in disenfranchised communities.
For health educators, two aspects of our role may be crucial: (1) to serve as a
resource and help create favorable conditions and opportunities for people to
share in community dialogue and change efforts: and (2) to engage m the em
powerment process as partners, plunging ourselves equally into the learning
process. For this role as a partner, we need to ask. what can we learn about
ourselves, our own racism, or how resources are controlled by our own insti
tutions? What happens to our practice if we deny our own positions of power.
A third challenge is the question of power itself. As health educators, we are
not interested in a process of empowerment that entitles some people to oppress
others as they increase their own power. Our ideal may be to create a communi y

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articles ' 'sent alternative and possibly dialectical views of power: as an ex
panding source of greater shared power or as a resource to be taken by one
group from another, so as to transform inequitable social power relations. These
different views of power, and the conflicts that may by engendered, become
important to identify and assess in empowering practice.
A fourth challenge is how to sustain a long-term commitment to the empow
erment process despite set-backs and the difficulty of guaranteeing immediate
results. When people are engaged in changing unjust conditions, they often
encounter frustrations that can lead to feeling greater powerlessness rather than
empowerment. Empowerment also may not be a fixed state, with individuals
and organizations having more or less power in different situations. The role of
critical thinking, examined in the articles, therefore becomes important in ana
lyzing the historical and social context, judging the limits or possibilities for
change, and sustaining participation in difficult times.

OVERVIEW OF THE ARTICLES IN THIS ISSUE

Our intention, with this two-issue set, is to sharpen the discussion on the
various dimensions of community empowerment and participatory education.
We hope that a critical reading of the theory, research, and practice described
in the articles will clarify issues and provoke further dialogue. The posing of
new questions will contribute to the evolution of community empowerment
practice and theory, participatory program evaluation, and the development of
qualitative and quantitative research designs.
Community empowerment in public health has its historic roots in many fields:
community psychology, social psychology, the World Health Organization and
Ottawa Health Promotion Charter mandating community participation, the liberatory and popular education philosophy of Brazilian educator Paulo Freire,
the Saul Alinsky and Myles Horton traditions of community organizing, and the
critical theory, feminist, and post-modernist schools.
From these influences, community empowerment, as both process and out
come, has emerged and continues to emerge in this two-volume set with common
themes: a social action process, people being “subjects” of their own lives,
connectedness to others, critical thinking, personal and social capacity building,
and transformed power relations. It is not a monolithic construct, however, nor
a panacea, but demands creative approaches to meet our societal and community
health challenges.
Julian Rappaport8 in his classic article, ‘Tn Praise of Paradox: A social policy
of empowerment over prevention,” argues that “a variety of contradictory so
lutions will necessarily emerge and that we ought not only to expect but welcome
them, the more different solutions to the same social problem the better... given
the nature of social problems there are no permanent solutions...”8 (p. 9). Health
educators need a broad repertoire of approaches to match various needs of
communities, organizations, and individuals in order to take advantage of chang
ing conditions and opportunities.
The articles in this issue present a wide variety of approaches to empowering

practice, responses io uic
following critical questions:

...........

1. What is empowerment? Empowerment by whom? For whom? And for
what end?
2. How is empowerment a process or an outcome?
3. What are the subjects or sites of empowerment? Do we focus on ourselves,
individuals, families, workplaces, communities or society as a whole—or
all of these?
4. Is empowerment always a positive process? Can individuals and groups be
empowered at the expense of others?
5. How do we know when we have empowerment? How can empowerment
projects be evaluated and measured effectively?
6. What is the best relationship to the people we work with? Which health
promotion practices empower and which disempower?

Two articles focus on theoretical questions: definitions and spheres of em
powerment, power, and relationship issues. Israel, Checkoway, Schulz, and
Zimmerman present a comprehensive view of individual through community
empowerment. They provide us with a conceptual model of stress that integrates
environmental factors, powerlessness, social support, and mental and physical
health status. The authors describe the development and implementation of an
instrument to measure perceived control across all levels of empowerment, and
advocate participatory action research for empowering practice.
Labonte’s article discusses empowering professional and institutional health
promotion practice, posing the question, “How do professionals, under the
rubric of health promotion, engage in new practice styles that reduce or amel
iorate inequitable social conditions?” Examining the relations implicit in em
powerment, this article contrasts “power over” with “power with,” or the process
of professionals hearing people name their experience and having that naming
be legitimized. Labonte offers an empowerment Holosphere model, based on
a belief that professionals and institutions are capable of changing their practice
to one of partnership with communities; and presents a case study of a Toronto
community health center to support his model.
Two articles provide new tools for measuring empowerment and community
competence, a related construct. Israel et al. developed and tested anew per
ceived control scale, with a discussion of its possibilities and limitations. Eng
and Parker describe an evaluation approach used for a rural community health
advisor program in the Mississippi Delta. Using an action research model, they
developed and applied a measurement instrument for community competency,
defined as the ability of a community to “pull it together.” The article also
focuses on the partnership relationship between evaluators and community
health advisors, and concludes that assisting people to empower their commu
nities is as important as assisting them to improve their health.
Two articles focus on naming the problem and solution as the driving force
behind programs engaged in empowering practice. Ovrebo, Ryan, Jackson, and
Hutchinson report on the success of the San Francisco Homeless Prenatal Pro
gram in transforming the lives of homeless pregnant women, by uncovering two

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giving back. Qualitative evaluation showed that the community health out
reach workt
ecruited from former homeless mothers provided peer support
and role models in an empowerment process in which homeless women could
move “from feelings of personal power to changing material conditions in order
to achieve whole reclamation of one’s life.”
Wang and Burris incorporate Freirian education, feminist theory, and photoducumentary efforts in a program that enables women in rural China to name
and analyze their problems. Using a Freirian participatory education process,
this project demonstrates how peasant women develop photo novellas (picture
stories), use them for group discussions around their collective health needs,
and become empowered as they “communicate their vision and voice... to policy
makers.”
Finally, two articles provide case studies of programs engaged in empowering
practice and empowerment goals. Plough and Olafson describe the challenges
and conflicts faced by a city health department trying to share power with
community groups and social service agencies within the limits set by a federally
funded infant mortality reduction program, the Boston Healthy Start Initiative.
The article describes an 18-month evolution of the program from a communitytargeted program to a partnership, and, more explicitly, to a community-directed
program, through the transfer of skills, authority, and budgets.
Eisen reports on a survey of 17 community empowerment initiatives to explore
the ways that these diverse programs defined and operationalized their com
mitment to community empowerment. The programs are compared by history
and neighborhood context, their planning process and structure, their goals and
objectives, their strategies, their relationship to their funders, and their accom
plishments. Eisen concludes that local participation, equal representation of
ethnic groups on governing boards, and an organization’s ability to gain influence
with local government and other boards are critical factors for community revitalization.
The articles in issue two will cover a range of theoretical, practical, and
evaluation research concerns. Several articles continue the theoretical dialogue
on empowerment, with one challenging the new tyranny of the concepts of
community participation and empowerment. Two lay health advisor programs
are presented, with their successes and barriers to achieving empowerment goals.
One article focuses on methodologic strategies to involve community members
in organizing. Two case studies of community change discuss the dialectical
interactions between university researchers and community members. One ar
ticle presents a cultural perspective, and advocates “border pedagogy” as a
strategy to value people’s voices. Freirian methodology is laced throughout
several articles, including a description of learner-generated curricula. Finally,
the importance of critical reflection is documented in a community development
project in an international setting and in critiques of several of the U.S.-based
programs.
This two-issue set of Health Education Quarterly represents the fruit of
over a decade of development and struggle regarding empowerment theory and
practice. With these articles, we hope to further challenge health educators and

146

other health professionals to engage in continual self

ection about our prac-

tice in community settings.

The relationship between people and professionals is expressed well by Lily
Walker, an Australian aboriginal woman, who offers us the following directs
“If you are here to help me, then you are wasting your time. Bu if you come
because your liberation is bound up in mine, then let us begin (p. 12.).

References

1. Wallerstein NB: Powerless, empowerment, and health: Implications for health pro-

Healtl Education and Community Empowerment:
Conceptualizing and Measuring Perceptions
of Individual, Organizational, and
Community Control
Barbara A. Israel, DrPH
Barry Checkoway, PhD
Amy Schulz, PhD
Marc Zimmerman, PhD

2

Presented at Christian Medical
CCPD Joint Comission Meeting, Manila, Philippines, January 1988. The Hespen
Foundation, P.O. Box 1692, Palo Alto, California 94302,
iggs
3 Mcknight JL: Health and empowerment. Can J Public Health Supp
Personal
4 Covey SR: The Seven Habits of Highly Effective People: Powerful Lessons in
i--------Chanee New York, NY, Simon and Schuster, 1989.
5 Hillerman A: Larry Wilson and the Corporate Trapeze. Southwest Airlines Magazme,

American Way Publishing, DFW Airport, TX, 1987.
on Transforming Education.
6 Shor I. Freire P: A Pedagogy for Liberation: Dialogues
South Hadley. MA, Begin and Garvey. 1987.
1283 -1284 199.3.
7 Skilnick A- NMA seeks prescription to end violence. JAMA „ •

S «“<.* > !"

«' P“d°- A

P°“CV

""P”'"

x?sax*-'-p””"’ r'"“” ™pr“tice. Health Educ Q 21:253 268, 1994.

The fundamental conditions and resources for health are peace, shelter, edu
cation, food, income, a stable ecosystem, sustainable resources, social justice,
and equity. Improvement in health requires a secure foundation in these basic
prerequisites.1

The prevailing emphasis in health education is on understanding and changing life
style choices and individual health behaviors related to health status. Although such
approaches are appropriate for some health problems, they often ignore the association
between increased morbidity and mortality and social, structural, and physical factors in
the environment, such as inadequate housing, poor sanitation, unemployment, exposure
to toxic chemicals, occupational stress, minority status, powerlessness or alienation, and
the lack of supportive interpersonal relationships. A conceptual model of the stress
process incorporates the relationships among these environmental factors, powerlessness
(or conversely empowerment), social support, and health status. The concept of em-

An earlier version of this paper was presented at the annual meeting of the American Public
Health Association, New York. New York, October 2,1990. We thank Sue Andersen for her con
tribution in preparing this manuscript. We express our appreciation to Steven Rosenstone who was
the Principal Investigator for the Detroit Area Study in which we developed and tested the mea
surement instrument presented here.
Barbara A. Israel is ’Associate Professor, School of Public Health, University of
Michigan, Ann Arbor.
Barry Checkoway is Professor, School of Social Work, University of Michigan, Ann
Arbor.
Amy Schulz is Research Associate, School of Public Health, University of Michigan,
Ann Arbor.
Marc Zimmerman is Assistant Professor, School of Public Health, University of Mich
igan, Ann Arbor.
Address reprint requests to Barbara A. Israel, DrPH, Department of Health Behavior
and Health Education, School of Public Health, The University of Michigan, 1420 Wash
ington Heights, Ann Arbor, MI 48109-2029.

Health Education Quarterly, Vol. 21 (2): 149-170 (Summer 1994)
' 1994 by SOPHE. Published by John Wilcv & Sons. Inc.

CCC 0195-8402/94/020149-22

idi

d professional fields,
powerment has been examined in diverse academic discipline?
However, there is still a lack of clarity on the conceptualization of empowerment at
different levels of practice, including its measurement, relationship to health, and ap
plication to health education. The purpose of this article is to address these issues as they
relate to the concept of community empowerment. It provides a definition of community
empowerment that includes individual, organizational, and community levels of analysis;
describes how empowerment fits within a broader conceptual model of stress and its
relationship to health status; and examines a series of scales that measure perceptions
of individual, organizational, community, and multiple levels of control. The article
concludes with broad guidelines for and barriers to a community empowerment approach
for health education practice.
INTRODUCTION

The prevailing emphasis in health education interventions is on understanding
and changing factors that affect life-style choices and individual health behaviors
related to health status. Although such approaches to changing individual be
havior are appropriate for addressing some health problems, they often ignore
the association between increased morbidity and mortality and social, structural,
and physical factors in the environment such as inadequate housing, poor san
itation, unemployment, exposure to toxic chemicals, occupational stress,
minority status, poor education,2-10 powerless or lack of control or aliena
tion,311-16 and the lack of supportive interpersonal relationships.217 A conceptual
model of the stress process incorporates the relationships among these environ
mental factors, powerlessness (or conversely empowerment), social support, and
mental and physical health status.2
Many of these risk factors are beyond the ability of any one individual to
control or change. Exposure to water contaminated by hazardous waste is neither
caused nor eliminated by a single individual but reflects social processes and
inequalities. Toxic production and waste facilities have been found to be dis
proportionately located in poor and minority communities whose residents lack
access to and influence over decision makers.18 Also, access to nutritious and
affordable food in low-income communities is not determined by the individuals
residing within them, but by processes of production and distribution that reflect
regional, national, and international corporate and governmental interests.
Health educators committed to improving health and well-being might want
“to teach” individuals how to find alternative water or food supplies, but this
approach has the danger of both blaming the victim19 and doing little to eliminate
the source of the problem itself. Health educators particularly committed to
meeting the needs of economically, culturally, or ethnically marginalized people
need to work with them to obtain the basic prerequisites of health as defined
by the Ottawa Charter for Health Promotion (presented above, 1). This requires
that health educators not just develop programs aimed at individual behavior
change, but also engage in collective action for social change.20-21 Application
of the concept of empowerment within a framework of the stress process at the
community level can provide health educators with useful guidelines for under
standing the complex determinants of health, and can inform the design, conduct,
and evaluation of communitv-based health education

The concep, empowerment has been examined at different levels of practice
in diverse academic disciplines and professional fields.3 7’8 11 16-22-31 Within this
literature, there have been numerous discussions of measurement issues and
calls for the development of instruments to measure empowerment. However,
there are still competing definitions and a lack of clarity on how empowerment
is conceptualized at different levels of practice, its relationship to health, its
measurement, and its application to health education practice. The purpose of
this article is to address these issues as they relate to the concept of community
empowerment. It provides a definition of community empowerment that includes
individual, organizational, and community levels of analysis; describes how em
powerment fits within a broader conceptual model of stress and its relationship
to health status; and examines a series of scales that measure perceptions of
individual, organizational, community, and multiple levels of control. The article
concludes with broad guidelines for and barriers to a community empowerment
approach for health education practice.

WHAT IS COMMUNITY?
To use the concept of empowerment and conceptual framework of the stress
process to guide health education strategies at the community level, it is im
portant to clarify what is meant by “community.” Although there are many
definitions of community,32-38 the one used here draws upon Sarason,33 Klein,32
and Steuart.34 A community is a locale or domain that is characterized by the
following elements: (1) membership—a sense of identity and belonging; (2)
common symbol systems—similar language, rituals, and ceremonies; (3) shared
values and norms; (4) mutual influence—community members have influence
and are influenced by each another; (5) shared needs and commitment to meeting
them; and (6) shared emotional connection—members share common history,
experiences, and mutual support. Communality may be geographically bounded
(e.g., a neighborhood), but is not necessarily (e.g., an ethnic group). Further
more, a city or catchment area may be just an aggregate of nonconnected people,
may include numerous communities, or may have little sense of communality.
Different neighborhoods within a city will vary in the extent to which they have
a sense of community.
,
This definition of community is important for the present discussion because
a community empowerment approach within the stress framework—with its
emphasis on collective analysis, action, and control—suggests that the health
educator needs to identify and work within contexts that already show some
sense of community. If this is not the case, then the initial task is to try to
strengthen communality, or recognize that the individual, family, or social net
work may be more appropriate as the unit of practice.

WHAT IS COMMUNITY EMPOWERMENT?
The concept of empowerment has been examined in diverse disciplines and

The purpose here is not to review this extensive liter;
e,8-26 30 rather, the aim
in this article is to highlight the major definitional and conceptual issues regarding
community empowerment within the context of the stress model, and to discuss
the relationship of these issues to health education practice and the measurement
of empowerment.
Empowerment, in its most general sense, refers to the ability of people to
gain understanding and control over personal, social, economic, and political
forces in order to take action to improve their life situations.24-27 30 In contrast
to reactive approaches that derive from a treatment or illness model, the concept
of empowerment is positive and proactive. Empowerment is often defined for
different levels of analysis and practice—for example, individual, organizational,
and community. Linkages among levels are a topic of considerable debate and
will be discussed following definitions of each of the levels.

Community Empowerment
An empowered community is one in which individuals and organizations apply
their skills and resources in collective efforts to meet their respective needs.
Through such participation, individuals and organizations within an empowered
community provide enhanced support for each other, address conflicts within
the community, and gain increased influence and control over the quality of life
in their community. Similar to an empowered organization, an empowered com
munity has the ability to influence decisions and changes in the larger social
system. Hence, empowerment at the community level is connected with em
powerment at the individual and organizational levels.43 This conceptualization
is similar to the definition of neighborhood empowerment as composed of “ca
pacity and equity,”46 where capacity is defined as the use of power to solve
problems and equity is defined as getting a fair share of resources.

Individual or Psychological Empowerment
Relationships among Multiple Levels of Empowerment

Individual or psychological empowerment refers to an individual's ability to
make decisions and have control over his or her personal life. It is similar to
other constructs such as self-efficacy39 and self-esteem41' in its emphasis on the
development of a positive self-concept or personal competence. In addition,
psychological empowerment incorporates the establishment of a critical or an
alytical understanding of the social and political context, and the cultivation of
both individual and collective resources and skills for social action.41 Thus,
empowerment at the individual level combines (1) personal efficacy and com
petence, (2) a sense of mastery and control, and (3) a process of participation
to influence institutions and decisions.26-42 Empowerment at the individual level
is linked with the organizational and community levels through the development
of personal control and competence to act, social support, and the development
of interpersonal, social, and political skills.41-43

Organizational Empowerment
The literature on organizational empowerment draws heavily from democratic
management theory.44 Empowering organizations are democratically managed,
in which members share information and power, utilize cooperative decision
making processes, and are involved in the design, implementation, and control
of efforts toward mutually defined goals. Consequently, they empower individ
uals as part of the organizational process. Empowering organizations recognize
and incorporate cross-cutting linkages among members, such as interest groups,
status groups, and formal subunits. An empowered organization also has influ
ence within the larger system of which it is a part.26-45 Thus, empowerment at
the organizational level incorporates both processes that enable individuals to
increase their control within the organization, and the organization to influence
policies and decisions in the larger community. This conception of organizations
as both empowered and empowering helps provide the link between the orga
nization level and the individual and

i......-.......................

♦

Researchers and practitioners continue to debate the relationships among
individual, organizational, and community levels of empowerment; whether the
three levels can be addressed separately or simultaneously; and whether one
level leads to another.45 Although professionals generally agree that all levels
need to be targeted, much of the literature on empowerment focuses on the
individual level. We argue that for empowerment to be a meaningful concept,
distinct from others such as self-esteem and self-efficacy, the cultural, historical,
social, economic, and political context within which the individual exists must
be recognized. It is possible to develop a program aimed at individual empow
erment, but if this does not consider the context in which the individual is
embedded—such as the organization or community—then there is less likelihood
that actual increases in influence and control and concomitant improvement in
health and quality of life will occur. Thus, although the three levels have im
portant independent properties, they are not mutually exclusive.
This perspective highlights not just empowerment at multiple levels, but also
the combination of empowerment across all three levels. Freire’s23 concept of
conscientization provides a foundation for linking these three levels. Conscientization involves the development of a sense of identification with a group, of
shared fate with that group, and of self and collective efficacy. The latter com
ponent involves both the belief that effective action is possible, and the capability
(skills and resources) to develop effective strategies for action. Through a dia
lectical process of collective reflection and action (i.e., praxis), individuals, or
ganizations, and the community as a whole develop the capacity to act effectively
lo create social change.22-23-47
Although we do not wish to suggest that a single focus on the individual,
organization, or community alone is not viable, we do argue that a model of
community empowerment that links all three levels provides the most effective
means to collectively provide the support and control necessary to develop
needed skills, resources, and change. This multilevel concept of community

at other levels.43 In accordance with this model, as actic at the organizational
or community level results in enhanced collective prob, .i-solving capabilities
and increased influence and control over resources, those individuals involved
in the process will experience greater control, and individual empowerment will
be increased. We use the term “community empowerment’ to refer to this
term
multilevel concept to clearly differentiate from the frequent use of
c. the
----------“empowerment” as an individual level construct.

Critical Issues and Dimensions of Community Empowerment

In addition to the definition of community empowerment, there are other
issues that also have implications for community health education practice and
research. These include the role and conceptualization of power; empowermen
as a process and outcome; actual or perceived empowerment; and domain and
’‘"rhe^role and conceptualization of power in relation to the concept of em
powerment have been addressed extensively in the literature.
The
responsible exercise of power is central to the concept of community empow
erment. A community empowerment model transcends hierarchical, patriarchal,
coercive or violent conceptualizations of power,45 and challenges the assumption
that power is a zero-sum commodity, that is increasing the power of one com
munity organization, or individual implies decreasing the power of another.
A community empowerment model emphasizes participation, caring, sharing,
responsibility to others, and conceives of power as an expanding commo i y.
Another central issue in the literature concerns whether empowerment is a
process and/or an outcome. Used as a verb, “to empower refers to a process
through which people gain influence and control over their lives, and hence,
become empowered. It is important here to distinguish between the primary
dictionary definition of “empower”-to invest or give power or authornyto
othersthe secondary
enable others, or to give others abilities
others; and
and the
secondary definition-to
definition
in order that they may obtain power through their own efforts. It is critical for
health educators trying to facilitate an empowering process, to adhere _to thi
latter definition. That is, health educators cannot 'give power to people but
can enable others to strengthen skills and resources to gain power over then

lives30
j
Used as a noun, empowerment refers to a state of being empowered as an
outcome of the process. Focusing on empowerment as an outcome of a health
education intervention provides one measure of the success of the Process,
one thing to know that people are engaged in a process of strengthening the
skills and resources needed to have influence and control over their lives. It is
another to know that the process results in the attainment of these goals and
the ability to transfer lessons learned in one situation to other areas.
e arg“e’
as have others,16-29-45 that empowerment is both a process and an outcome. 1 his
has important implications for intervention strategies and measurement. For
example different data collection methods are needed to assess the process of
collecflve action within a community, and the resulting increase in power and

control of the people involved.

This discuss; 'n leads to another issue regarding whether empowerment refers
to perceived i mgs of power and control, or to the actual reality of the reallocation of power and resources through structural change.29 Although percep
tion and subjective experience are critical, without actual changes in the objective
reality the end stage of empowerment has not occurred. From a measurement
perspective, this issue raises another concern regarding the limitations of using
only self-report measures (an example to be presented below) to assess objective
reality.
The process of empowering communities is dynamic and ever changing. A
community and its constituent individuals and organizations can be empowered
in some domains but not in others, and at some times but not at others.45 For
example, a community may be successful in influencing the development of
needed health services, but may not be as effective in keeping jobs in the
community. Empowerment cannot necessarily be achieved in the short run, but
takes commitment to a long-term process—that is empowerment over the “long
haul.”50
WHY A COMMUNITY EMPOWERMENT APPROACH
TO HEALTH EDUCATION?
Epidemiological, sociological, and psychological evidence of the relationship
between influence, control, and health, provide a rationale for a community
empowerment approach to health education. For example, studies show an
association between powerlessness (or similarly, learned helplessness, alienation,
exploitation) and mental and physical health status.311-16 Other research has
linked poverty—economic powerlessness—with high rates of social dysfunction,
increased morbidity and mortality, and decreased access to primary and pre
ventive care.3 Additional research has shown an association between the ex
perience of stress and the development of diverse physical, psychological, and
behavioral disorders.2-4-5152 The conceptual model of the stress process incor
porates most of these factors (e.g., control, poverty, stress, health status), and
is presented here as a useful framework for guiding health education community
empowerment interventions.
The evidence from research examining this conceptual model suggests that
stress is related to physiological, psychological, and behavioral outcomes; and
that psychosocial factors, including control, play an important role in modifying
levels of stress, health, or the relationship between stress and health.2-412-15-51"55
This framework is most often explained in terms of how an individual experiences
the stress process.2 There are also some examples of its use in the identification
of stress and the design of interventions at the organizational level.2,56’57 In
accordance with the community empowerment approach to health education
being suggested here, the framework will be described as a guide to understand
ing stress and health within a community context. Thus, similar to the multilevel
dimensions of community empowerment, the stress model presented here rec
ognizes the interrelatedness of the role of stressors on health and quality of life
at individual, organizational, and community levels.
The conceptual model of the stress process (Fig. 1) posits five major elements:
(1) stressors, or psychosocial-environmental conditions conducive to stress (e.g..

CONDITIONING VARIABLES: Individual and Situational Characteristics
Social

Psychological

Biophysical

e_g^ social support
- community control/

c.g. personality factors

e-g- age
- sex

empowerment

- personal control

- coping abilities

e.g. family
history
of illness

- health status

- community problem

- socio-economic

solving abilities

status

PSYCHOSOCIAL
ENVIRONMENTAL
CONDITIONS CONDUCIVE
I'O STRESS (STRESSORS)

SHORT-TERM RESPONSES
ENDURING HEALTH
OUTCOMES

TO STRESS (Strains)
Physiological e^-, elevated

1.

Mood pressure, headaches

- major life events,

e-fi.

(■cnetic

PERCEIVED
STRESS

leader)

- daily hassles
(disagreement with

—7

<7

(by individual and

government official)

cardiovascular disease,

helpless ness
Behavioral e^, alcohol use

3.
4.

4/

Physiological, e.g.

I.

Psychological e^ tenseness,

2.

- (death of a community

cancer.
Psychological, e^

2.

Ecological/environ men tai e-g.,

anxiety disorder,

reduced property values,

depression

reduction in jobs

community collectively)

Behavioral, e^-,

3.

- chronic strains (power

alcoholism

lessness, malnutrition)

Ecologkal/En vironmental,

4.

- cataclysmic events

e^. industry and residents

(discoveries of toxic

relocate, destroyed water

waste dumps)

quality, family and

- ambient environment

community disintegration

(exposure to hazardous

chemicals)

t
Figure 1.

Conceptual framework of the stress process:

Individual and community level.4-57

among variables. Dotted lines indicate the hypothesized buffering
Note: Solid lines between boxes indicate presumed direct relationships
the relationship between stressors and percetved stress, and perceived stress and short-term
effects of the conditioning variables on t.._
responses, and short-term responses and enduring health outcomes.

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an a community with
better able to deal with subsequent stressful situation
little control or influence.
The concept of social support—although not the focus of this article is
another conditioning variable in the stress model that has relevance to a com
munity empowerment approach. Extensive research suggests that social support
may directly enhance health regardless of stress level, as well as protect people
from negative consequences of stressful situations.2 Therefore, in those com
munities where members provide one another with emotional support (empathy,
love, caring), instrumental support (tangible aid, services), informational sup
port (advice, suggestions, information), and appraisal support (feedback, affir
mation, social comparison),4 members would be expected to be at less risk of
the negative effects of stress than in communities where such mutual support
does not exist.

HOW CAN COMMUNITY EMPOWERMENT BE MEASURED?
To evaluate health education community empowerment interventions, it is
important to develop a method for assessing the extent to which community
empowerment exists in a given community and for documenting its development
over time. There have been numerous discussions in the literature of measure
ment issues and calls for the development of instruments.16 The research liter
ature includes examples of quantitative measures that have assessed different
aspects of psychological or individual empowerment, such as perceived control,
sociopolitical control,6(1 individual political efficacy, and citizen participation.6 -1Others have described survey instruments that assess different aspects of an
empowering organization, such as participative decision-making,63 organiza
tional culture, and management style.64 Some studies have used qualitative ap
proaches (e.g., in-depth interviews, observations) to assess, for example, the
development of psychological empowerment among community leaders,41 and
political empowerment within a Native American community.65
Although there are some examples of measuring various aspects of different
levels of empowerment, we arc unaware of quantitative approaches that assess
the multilevel concept of community empowerment. In this section we describe
our experience in the development and pilot testing of such measures and discuss
the limitations of the indices. (For an excellent discussion of measurement issues
in general, see Wallerstein.16)

Methods

Our measurement draws on research through the Detroit Area Study (DAS),
a large, random sample survey conducted yearly at the University of Michigan.
The research objectives of the study change depending on the key faculty mem
bers who direct the project for a given year. The development of the survey
instrument, the drawing up of the sample, the collecting of data through faceto-face interviews, and the analysis of the data are carried out by graduate
students as part of their training experience, working in conjunction with the
facultv director and several full and part-time research staff members

The 1989
\S examined the social, economic, and political profile of the
city of Detroi. _nd two surrounding counties; community members’ views of the
most important problems facing their communities; and the nature and extent
of public involvement in community problem-solving.66 Face-to-face interviews
(approximately 1 hour in length) were conducted between April and August in
1989 with 916 randomly selected adults from 47 communities in the greater
Detroit area. This involved a multistage area probability sample of housing units
in the tricounty area, proportional to estimated sample size (466 residents), and
an oversampling of residents in the city of Detroit (450 residents).
Measures
In the fall of 1988, during the planning phase of the DAS, we were involved
in a seminar series on empowerment, and were challenged by the lack of mea
surement instruments consistent with our multilevel conceptualization of com
munity empowerment. Given the significant role of control at multiple levels as
a conditioning variable in the stress process (as depicted in Fig. 1), and our
commitment to conducting and evaluating community empowerment interven
tions, we considered it particularly important that such measurement tools be
developed. Thus, we created a set of 12 questions designed to assess individual
perceptions of control or influence at the three levels of analysis—individual,
organizational, and community—for inclusion in the DAS survey. Our purpose
was to develop indices measuring perceptions of control or influence at the three
levels of analysis, to test the reliabilities of these indices, to develop a single
scale including the three indices that could be used as a measure of the multilevel
concept of empowerment, and to examine the correlates of perceptions of control
by using other questions in the DAS survey.43 In accordance with our concep
tualization of community empowerment across all three levels, the intent of the
items at the organizational and community levels was to assess both perceptions
of individual influence within an organizational and community context and the
perceived influence of the organization and community within a broader sphere.
Our 12 questions were asked following others that inquired about the par
ticipants' involvement in numerous organizations (e.g., national organizations,
neighborhood organizations, churches). The respondents were asked to identify
all the organizations to which they belonged and to select the one that was the
most important to them. The questions measuring perceived control at the or
ganizational level were asked with regard to that organization. Participants who
were not members of any organizations were not asked these questions. A fourpoint response scale, ranging from 1 = disagree strongly to 4 = agree strongly,
was used for all the items. The 12 items measuring perceptions of control are
presented in Table 1.

Results

Based on the results of a factor analysis, three subscales were created by
summing the constituent items. Internal reliabilities of each of these indices and
the overall community empowerment scale (all 12 items) were calculated using
( ronbach's alpha as a measure of the average interitom correlation The three

Table 1. Perceived Control Scale Items: Multiple Levels oi lunpowuiuicm muiccd
For the first five items, the interviewer asked the participants
‘please answer the
following questions thinking about the organization that you identified as most impor
tant to you. Do you agree strongly, agree somewhat, disagree somewhat or disagree
strongly?”

1. I can influence the decisions that this organization makes.
2. This organization has influence over decisions that affect my life.
3. This organization is effective in achieving its goals.
4. This organization can influence decisions that affect the community.
5. I am satisfied with the amount of influence I have over decisions that this orga
nization makes.

The interviewer then commented that “I have been asking about your participation in
specific organizations. I am also interested in how much influence you think you have
in your life and in your community. I am going to read you a list of statements. For
each one, please tell me how strongly you agree or disagree.”
6. I have control over the decisions that affect my life.
7. My community has influence over decisions that affect my life.

8. I am satisfied with the amount of control 1 have over decisions that affect my
life.

9. I can influence decisions that affect my community.

10. By working together, people in my community can influence decisions that affeet the community.
11. People in my community work together to influence decisions on the state or
national level.
12. lam satisfied with the amount of influence 1 have over decisions that affect my
community.
Indices

Perceived control at the individual level includes items 6 and 8 above (alpha

.66).

Perceived control at the organizational level includes items 1 through 5 above (alpha
= .61).

uciwcun iiiuiviuuai anu organizational; .22 between individual and
community; a
39 between organizational and community.
Thus, the seule does appear to assess three levels of perceived control, and
the organizational and community level indices tap both perceptions of individual
influence within the two domains, and the perceived influence of the organization
and the community in the larger environment. The instrument also provides a
measure of community empowerment across all three levels as defined earlier.
In an investigation examining the correlates of these measures of perceived
control, we found that participation in organizations that attempt to influence
public policy, taking an active or leadership role in a voluntary organization,
and belief that taking action is an effective means to influence community de
cisions are important predictors of perceived control at the organizational and
community levels.43

Potential Uses of the Instrument

The perceived control indices could be used by a health educator engaged in
a community empowerment intervention for both assessment and evaluation
purposes. As part of the community diagnosis and needs assessment phases, the
questions could be asked of community members individually and/or in a group
setting and used to generate discussion among community members regarding
their definition of empowerment and their assessment of the level of influence
and control that individuals, organizations, and the community have as a whole.
1'he results of such a discussion could be used to guide the selection of specific
action strategies aimed at enhancing community empowerment involving all
three units of practice.
The measurement instrument could also be used in a survey to gather baseline
data on perceptions of influence and control within a community or communities.
Here again, the results of the aggregated survey data could be used to assess
the extent to which perceived control exists as a resource or lack of control is
present as a stressor that needs to be addressed. After the implementation of
relevant interventions, a follow-up survey could be conducted to evaluate any
changes in perceptions. Such a survey could also be used to investigate basic
research questions longitudinally to further our understanding of the community
empowerment concept, for example. What are the major correlates of com
munity empowerment? Hovl do perceptions of control differ within subpopu1lations in a community? How do these change over time?

Perceived control at the community level includes items 7, 9, 10. 11. and 12 above
(alpha = .63).

Perceived control at multiple levels includes all 12 items above (alpha

.71).

subscales correspond to perceived control at the individual level (the sum of
items 6 and 8 in Table 1, alpha = .66), the organizational level (the sum of
items 1 through 5, alpha = .61), and the community level (the sum of the values
for items 7, 9, 10, 11, and 12, alpha = .63). A multilevel scale that includes all
12 items was also created (alpha = .71). Correlations among the three subscales

Limitations of the Instrument

I he scales described here provide a partial measure of empowerment, ex
amining individual perceptions of control or influence at multiple levels. These
perceptions were assessed by the use of a survey instrument with closed-ended
items that are not able to capture the richness and complexity of the community
empowerment concept. For example, the development of conscientization,23
^hich has been identified as a key component of a multilevel empowerment

162

perspective, is not measured by these items, nor is thi
an assessment of the
broader social-political-economic-cultural context that affects empowerment.
The use of more in-depth, semistructured interviews, focus groups, and com
munity observations throughout a community empowerment intervention is
needed to better assess empowerment as both a process and outcome. However,
a relatively short survey instrument, as presented here, can be used with large
numbers of participants to assess the level of and any changes in community
empowerment. Thus, we suggest the simultaneous use of both quantitative and
qualitative methods to measure community empowerment over time, for the
purposes of problem identification, illumination of meaning, and triangulation

of results.67
A second limitation of this scale is that it measures individuals’ perceptions
of influence and control across levels. The scale neither measures actual control
nor obtains a collective assessment, at the organizational and community level,
of perceived or actual control. Here again, observational and group assessment
techniques would overcome these limitations. A third limitation of the scale is
that the definition of community was not incorporated into the questionnaire,
respondents answered the questions using individual and undetermined concep
tions of community. The instrument would be most useful for intervention pur
poses if all respondents within a particular community were asked to answer the
questions with the same community in mind.
Fourth, this instrument was developed and tested with respondents from a
large urban area in the midwest involving primarily persons of either AfricanAmerican or European-American descent. The concepts of community, control,
and empowerment may differ across cultures and regions, and these variations
need to be taken into consideration when adapting the scale to other areas.
Finally although this instrument was pretested with community members and
revised based on their feedback, it was developed by the researchers based on
their conceptualization of perceived control. An alternative approach, consistent
with the definition of empowerment, would be to actively involve community
members in the generation and testing of the questionnaire items.
Despite these limitations, as described earlier, the perceived control indices
have potential use for health educators engaged in community empowerment
interventions. It is important to acknowledge that many of these limitations
apply to all closed-ended survey instruments, and that the concomitant strengths
of using such a data collection approach are applicable to these indices as well
(e g generalizability, reliability). The indices presented here are considered to
be an initial formulation for assessing the multiple levels of perceived control.
One of the next steps in this instrument development process is to use this
measure in the context of a community empowerment intervention, along with
other assessment methods, and to refine the scales as appropriate.

GUIDELINES FOR A COMMUNITY EMPOWERMENT
PERSPECTIVE FOR HEALTH EDUCATION PRACTICE

Health educators need to consider numerous factors in the design, imple-

yond the scop
f this article to present a specific program example, rather a
broad approacn and several general guidelines for practice are suggested. In
adherence with the tenets of community empowerment, with its emphasis on
increased power and control across multiple units of practice, and given the
research evidence examining the stress model that depicts an association between
control as a conditioning variable and lack of control (e.g., powerlessness) as a
stressor and health status, we suggest the use of a participatory action research
approach. This approach involves practitioners, researchers, and community
members in a joint process to meet the specific needs (e.g., reduce stress,
enhance control) of the community (intervention objectives) and to increase,
for example, the understanding of empowerment and the effects of the inter
ventions (research and evaluation objectives). Participatory action research
(PAR) involves a cyclical problem-solving process of diagnosing, action planning,
action taking, evaluating, and specifying learning.68 The key characteristics of
the approach include (adapted from 56):

1. It is participatory. The needs and problems addressed are generated by
the community members themselves and not just by the theories and con
cerns of the health educators. The community members are involved in all
aspects of the action and research.68-71
2. It is a cooperative and co-learning process. Community members and health
educators engage in a collaborative, joint process in which both contribute
to and learn from each others’ “theories” and expertise.68-70-73
3. It is a reflective process that involves conscientization. Through a dialetical
process of collective reflection and action, the community and its constit
uent organizations and individuals develop a sense of identification and
shared fate and the skills and resources to engage in the cyclical process
of diagnosing and analyzing problems, and planning, implementing, and
evaluating strategies aimed at meeting identified needs.22 23-47
4. It is an empowering process. Through participation, community members,
organizations, and the community as a whole gain increased influence and
control, which is in turn associated with health and quality of life.2-73
5. It achieves a balance between research and action goals and objectives.
Health educators and community members jointly determine and strive to
maximize both increased knowledge and understanding of a given phe
nomenon, and jointly^ take actions to change the situation.74
Thus, in choosing to use a participatory action research approach, a health
educator can identify process and outcome goals and objectives that are con
sistent with the community empowerment concept. Using this approach, it is
not possible for the health educator to define specific health problems or be
haviors prior to joining with the community in this cooperative, co-learning
process. However, from the perspective of the stress model presented earlier,
the health educator can engage in a PAR project with the specified objectives
of identifying and addressing sources of stress in the community, and the exist
ence of conditioning variables (e.g., control, social support). The model of the
stress process and the concept of community empowerment are most helpful in
;

I •.

»

i , t

t

.

‘

■■■

1

♦ '

stressors that are beyond any one individual’s ability tc
itrol (e.g., inadequate
housing, violence, exposure to environmental hazards), in such situations, health
education interventions are needed that involve collective action aimed at com
munity and social change as well as individual behavior change.
Using a PAR approach within the context of the stress process suggests several
general guidelines for health education practice.

1. Program goals need to focus, at the community, organizational, and in
dividual levels, on reducing sources of stress (e.g., exposure to toxic wastes,
poverty) as well as strengthening conditioning variables that may have a
positive effect on stress and health (e.g., individual control, social support,
community empowerment).
2. Program participants need to be actively involved and have influence in
all aspects of program planning, implementation, and evaluation (e.g.,
interventions need to address the problems defined by the community itself
and need to be control-enhancing processes themselves).
3. Intervention outcomes need to include potential program effects on psy
chological, physical, behavioral, and ecological/environmental well-being,
not solely a categorical disease focus.
4. Program goals and objectives need to specify, and quantitative and qual
itative measurement instruments need to assess, both the process ot in
creasing influence and control (e.g., participation in community meetings),
and the outcome of the process (e.g., actual influence over a decision that
affects the community), across individual, organizational, and community
levels.
5. Program activities need to be carried out in ways that are consistent with
the concept of empowerment, use of consensus decision-making, sharing
of information and power, mutual respect and support, and ensure capacity
building.
6. Community-based activities need to balance efforts spent on action with
critical reflection aimed at conscientization.
These principles of practice flow directly from the model of the stress process
and the concept of community empowerment. Some are very similar to the basic
tenets of health education practice, especially the relevant community organi
zation models of community development, social action, and consciousnessraising.8-23,24-34,75-78 Numerous interventions have used these different models
with various populations and multiple goals, using different strategies and tactics,
but each including some focus on enhancing empowerment at the individual,
organizational, and/or community level. For example, interventions aimed at:
enhancing social support and social activism among low-income elderly com
munity members;79 substance abuse prevention among low-income Native Amer
ican, Hispanic, and Anglo youth;80 reducing stress and strengthening social sup
port in two low-income and working class rural communities;81 enhancing
leadership and advocacy skills among people with multiple physical and mental
disabilities;82 improving housing and neighborhood development involving
women of color within two low-income communities;83 capacity building in rural
communities and urban neinhborhnndv m

■<

education and mmunity organizing skills among Latina women;86 and reducing
stress and enii^ucing social support and control among workers in a manufac
turing setting.87 Hence, these models and case examples provide additional spe
cific suggestions for strategies and tactics appropriate for health education in
terventions aimed at community empowerment.
WHAT ARE THE BARRIERS TO A COMMUNITY
EMPOWERMENT PERSPECTIVE?

Although we advocate the application of the stress model and a community
empowerment PAR approach to health education, we also recognize that there
are limitations and barriers to this approach. These may specifically relate to
the community, to the health educator and his or her organization, and to
external factors. The barriers include:45-47

1. situations where community members1 past experiences and normative be
liefs result in feelings that they do not have influence within the system
(powerlessness, quiescence) and hence, they may feel that getting involved
in an empowerment intervention would not be worthwhile;
2. differences in, for example, social class, race, ethnicity, that often exist
between community members and health educators that may impede trust,
communication, and collaborative work;
3. role-related tensions and differences that may arise between community
members and health educators around the issues of values and interests,
resources and skills, control, political realities, and rewards and costs;74
4. difficulty in assessing/measuring community empowerment and being able
to show that change has occurred;
5. the health education profession does not widely understand and value this
approach;
6. risks involved with and potential resistance encountered when challenging
the status quo, for the individual, organizations, and community as well
as the health educator;
7. the short time-frame expectations of some health educators, their employ
ers, and community members are inconsistent with the sustained effort that
this approach require^ in terms of long-time commitment of financial and
personal resources;87
8. the collection and analysis of extensive amounts of both qualitative and
quantitative data to be used for action as well as evaluation purposes may
be perceived as slowing down the process;87
9. focusing on the local community may not be effective in the long run in
the context of today’s global world;*
As a colleague stated at a conference on empowerment: “In today's global world, what does
the empowerment of one community mean? Can it be separated from all similarly affected com
munities? If we empower one group of workers in Appalachia to fight toxic waste, we may simply
be moving the toxic chemicals to theThird World. Can empowerment occur at the individual or
community level without being inclusive of the links globally? If we don't address this global structure,
however, we can be turned against one another. So in the end we arc disempowered as we struggle
'> .th th.- I . • J :

•

’• /.

o\ I'

loo

This discussion is not intended to dissuade the int
ted health educator,
but rather to acknowledge that this is a complex process that cannot be accom
plished over the short term. Nor is it a panacea which, once implemented, will
resolve long-standing conflicts and inequalities. It is important to recognize t e
change process as developmental, that involves time and resources to enhance
local community empowerment, and to link communities together for mutually

beneficial collaboration in a more global community.

CONCLUDING COMMENTS

We realize that this community empowerment perspective is not appropriate
for all situations or for all health educators. Theory, however, is like a camera
lens that helps us focus what we see and how we work within a given frame.
Within this analogy, a telephoto lens brings fewer objects into focus and narrows
our field of view. Similarly, a theory that considers only the relationship between
individual behavior and physical illness allows only a narrow field of vision. On
the other hand, when looking through a wide-angle lens many objects are in
focus within a broad field of view; such is the case when using the stress model
and the concept of community empowerment to guide our interventions. We
suggest that health educators need to have multiple camera lenses in their rep
ertoire, in order to view the diverse people and situations with which we work.
These camera lenses then, and particularly the wide-angle lens that has been
presented here, can be used to guide our thinking and action. In engaging in
this process that at times can seem overwhelming, it is important to recall the
practice principle of educator Myles Horton50 that nothing good comes from
desperation and despair, rather real change comes through hope.

References

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rianv
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rh^rtnt.nn T Im-

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etary’s Task Force: Report on Black and Minority Health, Vol. 1.
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*
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Vol. 9, No. 1
Printed in Great Britain

HEALTH PROMOTION INTERNATIONAL
©Oxford University Press 1994

Empowerment: the holy grail of health promotion?
CHRISTOPHER RISSEL
School of Public Health, Division of Epidemiology, University of Minnesota, Minneapolis, MN, USA

SUMMARY
Potentially, empowerment has much to offer health
promotion. However, some caution needs to be exer
cised before the notion is wholeheartedly embraced as
the major goal of health promotion. The lack of a clear
theoretical underpinning, distortion of the concept by
different users, measurement ambiguities, and structural
barriers make 'empowerment' difficult to attain. To

further discussion, this paper proposes several assertions
about the definition, components, process and outcome
of 'empowerment', including the need for a distinction
between psychological and community empowerment.
These assertions and a model of community empower
ment are offered in an attempt to clarify an important
issue for health promotion.

Key words : community health; community organization; empowerment
\

INTRODUCTION

Health promotion advocates have not well articu
lated what exactly is meant by ‘empowerment’ in
the health promotion context, and the ambiguity
surrounding the concept is a major stumbling
block for the field. Being practical and problemoriented, and largely atheoretical, health promo
tion (and public health) tends to borrow
somewhat haphazardly from more theory-based
disciplines such as political science, psychology
and sociology (Bunton and Macdonald. 1992).
As a result, theory laden terms are used in health
promotion without considering the tradition
behind these terms—empowerment being one of
the latest in fashion.
For example, a majority difficulty for the
development and application of empowerment
theory in health promotion has been the lack of
clarity regarding the focus of empowerment
(Tones, 1984a, b, 1992). The dynamics of indi
vidual psychological empowerment are very
different from those of political action and com
munity empowerment, and the difference has
implications for health promotion practice.
This paper proposes that a distinction be made

between psychological empowerment and com
munity empowerment, where psychological
empowerment is considered at an individual
level, and community empowerment is con
sidered a collective phenomenon but including a
psychological component. This distinction is dis
cussed below. The paper is organized in four main
sections. First, the major obstacles to the whole
sale use of empowerment in health promotion are
considered. Second, the diverse literature is
reviewed for agreement on what empowerment
constitutes. Third, the process of empowerment is
explored and a model of psychological and com
munity empowerment presented. Finally, issues
for health promotion are discussed, and some
assertions made for discussion.
OBSTACLES TO EMPOWERMENT
HEALTH PROMOTION

IN

A closer look at the literature on empowerment
reveals some major obstacles to its wholesale use
in health promotion. Primarily, empowerment

39

and definition in a
as no doubt contri)werment has often
n well quantified or
major writers about
jficit, except Rappaempowerment could
only be considered
e context. UnfortunIvocates skirmishing
gists and hospital
ces, an inability to
live) impacts associt serious drawback,
pt and definition of
>r the misappropria(1991) argues that
ilth establishment’s
nands for increased
health, and that
power communities
attempts by health
lotion is essentially
venson and Burke,
sents some form of
must be exercised
it strategies in topSome critics question
ossible in situations
those without power,
ictural inequality of
teraction. According
7) there is a ‘fundapeople empowering
istitutional structure
lion to empower also
>f empowerment'.
argued that there is
il definition of emincrease of power of
• power of another
lot have to be seen as
as a lwin-win' situa
te in a psychological
political sense where
ikely that entrenched
ol of resources with(Baum, 1990). Swift
that empowerment
tem-change will be
ilement in western

obstacles before empowerment is widely used as
the yardstick by which health promotion ; ;es
itself. The following section reviews the em
powerment literature, and builds the case for
distinguishing between psychological and com
munity empowerment.

EVOLVING DEFINITIONS OF
EMPOWERMENT
There are a few concepts in health promotion
with as much potential as that termed 'empower
ment'. It embodies the raison d'etfe of health
promotion, ‘the process of enabling people to
increase control over, and to improve their health’
(World Health Organization, 1986) and arguably
should be a major goal of every health promotion
program (Braithwaite and Lythcott, 1989; Breslow, 1992). Unfortunately, it is also a greatly
abused term, with many papers from a range of
disciplines describing programs asserting the
empowering nature of projects (e.g. McKay et al..
1990; Fleury. 1991; Pizzi, 1992; Lower et al..
1992) without appearing to consider what
empowerment means or entails.
Empowerment is a complex notion, borrowing
from many bodies of literature. It is an idea shown
to be rooted in the civil rights and women's move
ments, the ‘social action' ideology of the 1960s.
and the ‘self-help’ perspectives of the 1970s
(Kieffer, 1984; Eng et al., 1992). Promoted in the
1980s as a principal theory of community
psychology (Rappaport, 1981: Rappaport et al..
1984; Rappaport, 1987), empowerment was
significant for community psychology in that it
acknowledged the person as a ‘citizen’ within a
political as well as social environment. In the
1990s it can be seen as part of the growing general
movement towards greater control by citizens in
many areas of life, including medicine (Illich.
1976), health education (Brown and Margo.
1978), the self-help movement (Rappaport.
1985), the physical environment (Auer, 1989)
and nursing homes (Kari and Michels. 1991).
Rappaport (1981, p. 15) described the aim of
empowerment as 'to enhance the possibility for
people to control their own lives'. No distinction
was made between ‘people' as individuals or
collective groups. Similarities with the World
Health Organization (WHO) (1986) definition of

eroup and can not be given to a group or com
munity. More recent definitions capture this
aspect:
Empowerment is viewed as a process: the mechanism
by which people, organizations and communities gain
mastery over their lives (Rappaport et al., 1984),
A process through which people become strong enough
to participate within, share in the control of andinflu
ence, events and institutions affecting their lives (Torre,
1986);
Psychological empowerment may be generally de
scribed as the connection between a sense of personal
competence, a desire for, and a willingness to take
action in the public domain (Zimmerman and Rappa
port, 1988);
The ability to act collectively to solve problems and
influence important issues (Kari and Michels, 1991);
A social-action process that promotes participation of
people, organizations and communities towards the
goals of increased individual and community control
political efficacy, improved quality of life and social
justice (Wallerstein. 1992).

mem, although the reverse is not necessarily li ue
Groups with high levels of reported psychological
empowerment may not have much control over
resources.

THE PROCESS OF EMPOWERMENT

Several recent reviews have identified the work of
Saul Alinsky. Paulo Friere, and Jack Rothman as
the intellectual and practical basis of the concept
of community empowerment (Swift and Levin,
1987; Wallerstein and Bernstein, 1988; Gibson,
1991; Fahlberg et al., 1991; Eng et al., 1992;
Wallerstein, 1992). Looking at the descriptions of
empowerment provided in the literature, it seems
that a common process of personal development,
participation, consciousness raising and social
action is evident. A few key examples are sum
marized below.
Kieffer (1984) studied 15 grassroots citizen
leaders of community organizations and looked
at the process by which these people became
psychologically empowered. He identified four
The more recent definitions begin to reflect an
stages in the empowerment process. The first, the
important distinction made by Swift and Levin
'era of entry' covers the initial tentative explora
(1987) between the subjective experience ot
tion of authority and power. The second stage, the
psychological empowerment and the objective
‘era of advancement', is characterized by a men
reality of modified structural conditions for the
toring relationship and supportive peer relation
purpose of reallocating resources. As will be
ships, where dialogue and mutual problem
argued below both of these components are neces
solving contribute to an increase in critical
sary for community empowerment, although a
understanding. The third stage, the ‘era of incor
distinction should be made between psychological
poration’ covers the development of organiza
empowerment and community empowerment.
tional and political skills and confronting activity.
It is important to make this distinction. Psycho
The fourth stage, the ‘era of commitment is a time
logical empowerment can be defined as a feeling
of integration of these social actions into the
of greater control over their own lives which
reality and structure of everyday life.
individuals experience following active member
Torre (1986) proposed that there were three
ship in groups or organizations, and may occur
essential components of community empower
without participation in collective political action.
ment, micro factors (referring to intra-personal
Community empowerment includes a raised level
aspects such as developments of self-esteem and
of psychological empowerment among its me111"
self-efficacy (Bandura, 1982, 1986)|, mediating
bers, a political action component in which
structures (referring to the group mechanism
members have actively participated and the
whereby members through their active participa
achievement of some redistribution of resources
tion shared knowledge and raised their critical
or decision making favorable to the community or
consciousness (Friere, 1973)|, and macro factors
group in question. An increase in a sense ot
(referring to the social and political activities).
psychological empowerment does not need to be
According to Torre, unless all three components
at the expense of others. However, by the above
are present then community empowerment can
definition, community empowerment means that
not occur. For example, in circumstances where
control over resources (which are limited) is
community self-help groups are formed for the
redistributed, which means that some people gain

S-vAk.'^^

Empowerment: the holy grail of health promotion ? 41
^■-

40

C. Rissel

still lacks a clear theoretical underpinning with
key elements articulated and supported by
research findings.
This absence of theory and definition in a
health promotion context has no doubt contri
buted to the fact that empowerment has often
been discussed but not been well quantified or
measured. Virtually all the major writers about
empowerment lament this deficit, except Rappa
port (1987) who argued that empowerment could
not be measured, but could only be considered
case by case in its own unique context. Unfortun
ately for health promotion advocates skirmishing
with medical epidemiologists and hospital
administrators over resources, an inability to
document positive (or negative) impacts associ
ated with ’empowerment’ is a serious drawback.
The lack of a clear concept and definition of
empowerment also allows for the misappropria
tion of the term. Grace (1991) argues that
empowerment is the health establishment’s
response to community demands for increased
control over their own health, and that
approaches that aim to empower communities
mask a priori controlling attempts by health
professionals. Health promotion is essentially
bureaucratically based (Stevenson and Burke.
1992) and, therefore, represents some form of
authority, so that vigilance must be exercised
against using empowerment strategies in topdown disempowering ways. Some critics question
whether empowerment is possible in situations
where power is bestowed to those without power,
without addressing the structural inequality of
power represented in this interaction. According
to Gruber and Tricket (1987) there is a ‘funda
mental paradox in the idea of people empowering
others because the very institutional structure
that puts one group in a position to empower also
works to undermine the act of empowerment’.
Swift and Levin (1987) argued that there is
nothing in the psychological definition of em
powerment that requires the increase of power of
one group to decrease the power of another
group, and that power does not have to be seen as
a zero-sum commodity, but as a ‘win-win’ situa
tion. Whilst this may be true in a psychological
sense, it does not apply in a political sense where
resources are scarce. It is unlikely that entrenched
groups will relinquish control of resources with
out some degree of conflict (Baum, 1990). Swift
and Levin did conclude that empowerment
programs directed at system-change will be
extremely difficult to implement in western

capitalist cultures that subscribe to the zero-sum
concept of power.
Health promotion needs to address these
obstacles before empowerment is widely used as
the yardstick by which health promotion judges
itself. The following section reviews the em
powerment literature, and builds the case for
distinguishing between psychological and com
munity empow'erment.

EVOLVING DEFINITIONS OF
EMPOWERMENT
There are a few concepts in health promotion
with as much potential as that termed^empowerment'. It embodies the raison d'etre of health
promotion, ‘the process of enabling people to
increase control over, and to improve their health'
(World Health Organization, 1986) and arguably
should be a major goal of every health promotion
program (Braithwaite and Lythcott, 1989; Bresiow, 1992). Unfortunately, it is also a greatly
abused term, with many papers from a range ol
disciplines describing programs asserting the
empowering nature of projects (e.g. McKay et al..
1990; Fleury, 1991; Pizzi, 1992; Lower et al..
1992) without appearing to consider what
empowerment means or entails.
Empowerment is a complex notion, borrowing
from many bodies of literature. It is an idea shown
to be rooted in the civil rights and women's move
ments, the ’social action' ideology of the 1960s.
and the ’self-help' perspectives of the 1970s
(Kieffer, 1984; Eng etal.. 1992). Promoted in the
1980s as a principal theory of community
psychology (Rappaport, 1981; Rappaporl et al..
1984; Rappaport, 1987), empowerment was
significant for community psychology in that it
acknowledged the person as a ’citizen' within a
political as well as social environment. In the
1990s it can be seen as part of the growing general
movement towards greater control by citizens in
many areas of life, including medicine (Illich.
1976), health education (Brown and Margo.
1978), the self-help movement (Rappaport,
1985), the physical environment (Auer, 1989)
and nursing homes (Kari and Michels. 1991).
Rappaporl (1981, p. 15) described the aim of
empowerment as ’to enhance the possibility for
people to control their own lives'. No distinction
was made between ‘people' as individuals or
collective groups. Similarities with the World
Health Organization (WHO) (1986) delinition of

health promotioni are obvious. Since 1981 the
definition has altered slightly to reflect the notion
that empowerment must come from within a
uroup and can not be given to a group or com
munity. More recent definitions capture this
aspect;
Empowerment is viewed as a process: the mechanism
by which people, organizations and communities gain
mastery over their lives (Rappaport et al.. 1984);
A process through which people become strong enough
to participate within, share in the control of and influ
ence, events and institutions affecting their lives (Torre,
1986);
Psychological empowerment may be generally de
scribed as the connection between a sense of personal
competence, a desire for. and a willingness to take
action in the public domain (Zimmerman and Rappa
porl, 1988);
The ability to act collectively to solve problems and
influence important issues (Kari and Michels. 199 );
A social-action process that promotes participation of
people, organizations and communities towards the
coals of increased individual and community control,
political efficacy, improved quality of hie and social
justice (Wallerstein. 1992).

:<

that
at the expense of others. It might be expected mat
groups with actual control over resources have a
high level of reported psychological empower
ment, although the reverse is not necessarily true
Groups with high levels of reported psychological
empowerment may not have much control over
resources.
■

iS- kA

THE PROCESS OF EMPOWERMENT

Several recent reviews have identified the work of
Saul Alinskv, Paulo Friere. and Jack Rothman as
the intellectual and practical basis ol the concept
of community empowerment (Swift and Levin.
1987; Wallerstein and Bernstein, 1988; Gibson,
1991; Fahlberg et al.. 1991: Eng et al.. 1
Wallerstein. 1992). Looking at the descriptions of
empowerment provided in the literature, it seems
that a common process of personal development,
participation, consciousness raising and social
action is evident. A few key examples are sum
marized below.
Kieffer (1984) studied 15 grassroots citizen
leaders of community organizations and looked
al the process by which these people became
psychologically empowered. He identified lour
The more recent definitions begin to reflect an
stages in the empowerment process. The first, the
important distinction made by Swift and Levin
•era of entry’ covers the initial tentative explora
(1987) between the subjective experience ol
tion of authority and power. The second stage, the
psychological empowerment and the objective
’era of advancemem', is characterized by a men
reality of modified structural conditions for the
toring relationship and supportive peer relation
purpose of reallocating resources. As will be
ships. where dialogue and mutual problem
argued below both of these components are neces
solving contribute to an increase in critical
sary for community empowerment, although a
understanding. The third stage, the ’era ol incor
distinction should be made between psychological
poration’ covers the development of organiza
empowerment and community empowerment
tional and political skills and confronting activity.
It is important to make this distinction. I sycnoThe fourth stage, the 'era of commitment is a time
logical empowerment can be defined as a feeling
of integration of these social actions into the
of greater control over their own lives which
reality and structure of everyday life.
individuals experience following active member
Torre (1986) proposed that there were three
ship in groups or organizations, and may occur
essential components of community empower
without participation in collective political action.
ment. micro factors (referring to intra-personal
Community empowerment includes a raised level
aspects such as developments ol sell-esteem and
of psychological empowerment among its mem
self-efficacy (Bandura. 1982. 1986)|. mediating
bers. a political action component in which
structures (referring to the group mechanism
members have actively participated, and the
whereby members through their active participa
achievement of some redistribution ol resources
tion shared knowledge and raised their critical
or decision making favorable to the community or
consciousness (Friere. 1973)|. and macro tacloi s
group in question. An increase in a sense ot
(referring to the social and political activities).
psychological empowerment does not need to be
According to Torre, unless all three components
at the expense of others. However, by the above
are present then community empowerment can
definition, community empowerment means that
not occur. For example, in circumstances where
control over resources (which are limited) is
community self-help groups are formed tor the
redistributed, which means that some people gain

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42

C. Rissel

purpose of increasing self-efficacy or self-esteem,
no matter how much the group members particip
ate in the process, there could not be community
empowerment unless there was a social action
component addressed at increasing the power of
the group. Participants could experience an
increase in psychological empowerment in this
example.
Swift and Levin (1987) proposed a three stage
model from a class consciousness perspective,
where each stage was a pre-requisite for the next.
According to this view, to become empowered a
person would first reach some critical conscious
ness of their powerlessness. Second, this person
would feel strongly about this inequity, and
through social interaction begin to feel comrade
ship with like-minded persons. Finally, the group
would then engage in deliberate action addressed
at changing the social conditions creating the
powerlessness. The combination of all three
stages are needed for community empowerment
(Swift and Levin, 1987).
Community organization and community
development are closely related to the process of
community empowerment. Minkler has compre
hensively described the principles of community
organization (Minkler and Cox, 1980; Minkler,
1990, 1992). Chavis and Newbrough (1986)
essentially equate community development with
the process of psychological and community
empowerment. In many ways it would seem that
community development or organization are the
means by which communities or groups might
become empowered, perhaps with the assistance
of an organizer who facilitates this process.
Therefore, the community health development
continuum, developed almost simultaneously on
two continents (Jackson et al., 1989; Labonte,
1989a, b), is a useful schema for representing the
community empowerment process. The potential
of community empowerment is maximized as the
focus shifts from the individual to collective social

action (see Figure 1). although the process need
not be simply linear with one stage automatically
following the other.
The process of community empowerment
begins with an assumption that a power deficit or
an unattended social problem exists, despite the
presence of some competencies. By contrast, an
empowered community logically should include
groups of individuals who have a raised sense of
empowerment. Psychological empowerment may
require some individual personal development,
such as increases in self-esteem or self-efficacy
(Bandura, 1982), at least to the point where that
individual is willing and able to join a group and
function effectively within it.
Joining mutual support, self-help or action
groups, builds and expands social networks and
provides an opportunity for a personal mentor
(Kieffer, 1984) or group to support a personal
development process. At the same time, indi
viduals may become critically aware of how
political structures operate and affect them and
their groups, or this critical consciousness raising
may occur through participation in a group or
other mediating social structure. Participation in
and influence of a group or organization is an
important stage of both psychological and com
munity empowerment (Green, 1986; Florin and
Wandersman, 1990). It is often the means by
which people learn skills which they may then be
able to transfer to other situations (Wandersman.
1981), and how communities develop their prob
lem solving capacity (Batten, 1967).
Participation in collective action is also funda
mental to the successful redistribution of
resources, which is necessary before a communiiy
or group can be said to be empowered. The
emphasis on community action as a core com
ponent of community empowerment (Brown.
1991) is also consistent with the principles ol
health promotion (Miner and Ward. 1992) and
voluntary organizations (O'Connell, 1978). Issues

being addressed by the
should be or have been
Ideally, the outcome of tl
ment process is a greater
empowerment among co
before the process, am
control over resources.
Another concept wh
community empowerme
ity' (Wallerstein. 1992).
of sense of community ex
Chavis (1986) and Cha\
linked to an incr^<e ii
organizations (V
ler
1980; Florin and W;
political participation
1989), such that an im
munity leads to an ir
(Chavis and Wandersm
focusing coping behavio
1985).
In the broader sense
(for example, a professk
lists), a community and
have some parallel wi
Indeed, the words ‘con
often used interchange
psychology literature. 1
groups or communities i
which groups exert in
participate and act soci
and Chavis (1986) ackn
members also are attract
they feel they are ^fluei
operate concurn y.
A visual representati'
cussion of the compon

Empowerment

*

deficit

Personal
development

Mutual
support
groups

— Psychological empowerment deficit

Issue identification
and campaigns/
community
organization

Participation in
organizations'
coalition
advocacy

Collective political and
social action

1
Personal
development

Communiiy empowermeni"

Fig. 1: Conceptual stages of community development for maximizing community empowerment potential (adapted
from Jackson et al., 1989; Labonte, 1989a, b)

Fig. 2: Model of the critica

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Empowerment: the holy grail of health promotion ? 43
Ithough the process need
h one stage automatically

mmunity empowerment
on that a power deficit or
oblem exists, despite the
etencies. By contrast, an
logically should include
10 have a raised sense of
gical empowerment may
personal development,
-es
i or self-efficacy
to ine point where that
able to join a group and
1 it.
>rt, self-help or action
ids social networks and
for a personal mentor
’ to support a personal
1 the same time, indiitically aware of how
te and affect them and
al consciousness raising
cipation in a group or
ucture. Participation in
1 or organization is an
psychological and comreen, 1986; Florin and
is often the means by
vhich they may then be
tuations (Wandersman.
lies develop their proben,
>7).
ve action is also fundaful redistribution of
iry before a community
* be empowered. The
action as a core comnpowerment (Brown,
with the principles of
and Ward. 1992) and
Connell,! 978). Issues

Collective political and
social action

tmmuniiy empowerment

being addressed by the group or community
should be or have been identified by the group.
Ideally, the outcome of the community empower
ment process is a greater degree of psychological
empowerment among community members than
before the process, and an actual increase in
control over resources.
Another concept which has been linked to
community empowerment is ‘sense of commun
ity (Wallerstein, 1992). A theory of the concept
of sense of community expanded by McCillan and
Chavis (1986) and Chavis et al. (1986) has been
linked to an increase in participation in block
organizations (Wandersman and Giamartino,
1980; Florin and Wandersman. 1984) and
political participation (Davidson and Cotter,
1989), such that an increase in sense of com
munity leads to an increase in participation
(Chavis and Wandersman, 1990) and problem19C85)ng C°ping behaviors (Bachrach and Zautra,
In the broader sense of the word “community'
(for example, a professional community of scien
tists), a community and its cohesiveness seems to
have some parallel with group cohesiveness.
Indeed, the words “community' and “group' are
often used interchangeably in the community
psychology literature. Pressure to conform in
groups or communities may be the mechanism by
which groups exert influence on members to
participate and act socially, although McMillan
and Chavis (1986) acknowledge that community
members also are attracted to communities where
they feel they are influential and that these forces
operat^concurrently.
A visual representation of the preceding dis
cussion of the components of community em-

powerment is presented in Figure 2. It can be seen
that the process of psychological empowerment is
enhanced by the sense of community, and that
psychological empowerment plus collective
political or social action plus an actual increase in
control over resources (to some degree) con
stitute community empowerment.

ISSUES FOR HEALTH PROMOTION

How does empowerment relate to health?
While there is no specific research documenting
an increase in a psychological state of empower
ment leading to improvements in physical health,
there is ample evidence that groups without power,
or who reported feeling powerless, experience
worse health. However power is measured, those
with more power are healthier (Smith, 1990Labonte, 1992). Wallerstein (1992) cites some
evidence that social support contributes to health
in a non-specific way, and it is conceivable that
the psychological state of empowerment may
effect physical health in the same way. From a
mental health perspective, individuals or groups
reporting increased levels of psychological
empowerment is the goal of community psycho
logy.
Community empowerment offers possibilities
for demonstrating direct physical health improve
ments through the effects of structural changes
achieved through collective political action.
However, consequences of community empower
ment may not be attributable to specific compo
nents. It may be the synergy of components that
leads to possible health gains. Also, it is not yet pos
sible to determine what degree of control over

Community
—-------------------- —^^empowerment
Psychological empowerment

Empowerment /
I__________
deficit
\ Personal
/ Mutual
1 development
support
\
groups

2
Issue identification
and campaigns/
community
organization

5

Participation
in organizations/
coalition advocacy

Collective iilll+ Degree of success in imnfr Health
political +
gaining control over
/ social action
resources

Sense of

community

ment potential (adapted
Fig. 2: Model of lhe critical components of community empowerment and the process by which it may be achieved

vsumed that ‘empowerd an outcome. When the
veen psychological and
it it is readily seen that
hough a process of perdevelopment operates
a psychological sense of
ssed above community
le state of psychological
is some change in the
(social action may be
f ees). At this time there
etermining what degree
rment has been attained
powered a community
essing changes in the
nt, as recommended by
<immerman (1990), to
jwerment is also not yet
i al., 1991).
>mena?
e components of comnecessary before a pro
ven empowering for a
n the process and out'•owerment must be a
m individual one. This
ogical empowerment,
felt in control of him/
roup of some kind and
n that person would be
vvered. However, this
erforms these actions
ontext, and is dependii were to benefit at the
>cess could hardly be

en contribute a great
empowerment, and
wards in the process
nces where individual
politically active they
ly thought of as emremembered that they
erful, i.e. are powerful
)up of supporters, and
ort.

iiuni activity on a single issue to
transfer to all areas of life leading to bef* - health
seems optimistic. The ability to Iran / skills
learned during an empowering process ma\
contribute to greater power in another life
domain, but there is no particular reason why the
psychological state should transfer. Also, once a
certain level of psychological empowerment is
achieved there is no reason to expect that it
should remain at that level.
With regard to community empowerment, ii
seems possible that a group may be empowered
on one issue, but not another. Therefore, the !
degree of empowerment may vary depending on
the issue being considered. This suggests that
community empowerment is topic specific. The ■
more issues in which a given group has influence
or control of resources, the more powerful that
group or community is likely to be. However,
circumstances may change such that the group
experiences a set-back, even though the level of J
resource control achieved is unaltered. Groups
that pay attention to group maintenance issues
and sub-production systems (achievement of '
tasks and objectives) increase their prospects of
longer-term viability (Prestby and Wandersman,
1985).
Special populations?
Different sub-groups, such as children (Kalnins et
al., 1992), isolated rural communities (Hughes,
1987; Jenkins, 1991) and the chronically poor
and homeless (Winkle and Ward-Chene, 1992),
are particularly powerless or dependent on others
and so present significant barriers for community
empowerment. On the one hand, these are exactly
the groups with the largest empowerment deficit,
but also the groups with the most barriers to
empowerment. Such special populations may
require more active encouragement to work
towards psychological and community empower
ment, by establishing frameworks that at least set
the process in motion, and support it to some
degree (Jenkins, 1991).

What is the role of the health promoter?
‘Enabling’ people to increase control over their
health suggests some action on behalf of the
health professional. But ‘taking over' any com
munity development activity is the antithesis of
any empowering process (Batten, 1967). The

inigm cuiiuiuuic io me process by en
couraging and supporting community initiatives,
and the establishment of infrastruc
and
svstems which promote political activity. Efforts
within mediating structures, perhaps in a mentor
ing role or by building membership or mainten
ance activities, while not reported as the most
personally rewarding of tasks (Revenson and
Cassel, 1991) may contribute a great deal. Profes
sionally initiated projects may become empower
ing if communities or groups can organize them
selves and act politically to take control of the
effort.

CONCLUSIONS

Several proposals have been asserted in this
paper. They are summarized here.
1. There is an important distinction between
psychological empowerment and community
empowerment. Psychological empowerment
is a feeling of greater control over their own
lives which individuals experience through
group membership, and may occur without
participation in collective political action.
Community empowerment includes a raised
level of psychological empowerment among
the community members, a political action
component in which members have actively
participated, and the achievement of some
redistribution of resources favorable to the
community or group in question.

2. Both psychological and community empower
ment are an outcome, although processes of
personal and community development oper
ate simultaneously to contribute to the
attainment of a psychological sense of
empowerment, and participation in collective
political action.
3. An increase in the control over resources (the
attainment of actual power) or a positive
change in the socio-political environment,
plus an increase in the reported level of
psychological empowerment are the appropri
ate end-points for evaluating an empower
ment program.

4. Community empowerment is a group pheno
menon and does not refer to individuals.

physical health in a non-specific way.

6. A change in the level of psychological em
powerment or control over resources for one
issue is unlikely to transfer to other areas.
Therefore, both psychological and community
empowerment are topic specific.
For work in the area of community empower
ment to proceed, common use of terms and
language would make communication easier.
Common understanding of the theoretical back
ground of the construct, keeping clear the distinc
tion between psychological and community
empowerment, and including all the critical com
ponents of community empowerment when using
the concept might avoid loose usage of the term.
Consideration of the disciplinary history of con
cepts used in health promotion might assist
common understanding (Bunton and Macdonald,
1992; Nutbeam, 1986).
Better quantification of the psychological
empowerment construct and means of assessing
changes in the socio-political environment should
be a high priority for health promotion research.
Better quantification would also allow better
study of the relation of empowerment to health
measures. Longitudinal studies are also needed,
looking not only at end-points, but at the process
and elements necessary for achieving community
empowerment. Funding agencies will need to be
convinced of this necessity.
ACKNOWLEDGEMENTS

The author would like to acknowledge the helpful
discussions and comments regarding earlier
drafts of this paper made by John Finnegan and
Kim Miner.
Address for correspondence :
Christopher Rissel
Division of Epidemiology
School of Public Health
University of Minnesota
Suite 300
1300 South Second Street
Minneapolis
MN 55454-1015
USA

44 C. Rissel

resources might be necessary for health improve
ments, and whether new or more resources are
necessary, or whether mobilizing existing
resources is sufficient.
Process or outcome?

It has been generally assumed that ‘empower
ment’ is both a process and an outcome. When the
distinction is made between psychological and
community empowerment it is readily seen that
both are an outcome, although a process of per
sonal and community development operates
simultaneously to lead to a psychological sense of
empowerment. As discussed above community
empowerment includes the state of psychological
empowerment, as well as some change in the
structural environment (social action may be
successful in varying degrees). At this time there
are no clear criteria for determining what degree
of psychological empowerment has been attained
and, therefore, how empowered a community
may have become. Assessing changes in the
socio-political environment, as recommended by
Wallerstein (1992) and Zimmerman (1990), to
evaluate community empowerment is also not yet
well developed (Bunton etal., 1991).

Individual or group phenomena?
If one accepts that all three components of com
munity empowerment are necessary before a pro
cess can be said to have been empowering for a
group or community, then the process and out
come of community empowerment must be a
group phenomenon, not an individual one. This
also applies to psychological empowerment.
Typically, if an individual felt in control of him/
herself, participated in a group of some kind and
performed a political action that person would be
considered to be empowered. However, this
hypothetical individual performs these actions
within a social and group context, and is depend
ent on others. If one person were to benefit at the
expense of others, the process could hardly be
said to be empowering!
Community leaders often contribute a great
deal toward community empowerment, and
receive some personal rewards in the process
(Rich, 1980). In circumstances where individual
leaders are socially or politically active they
would also be traditionally thought of as em
powered, but it should be remembered that they
are representationally powerful, i.e. are powerful
because they represent a group of supporters, and
are dependent on this support.

Empowennent: the holy grail of health promotion ? 45
Generalizability and maintenance
To expect a psychological state of empowerment
generated from activity on a single issue to
transfer to all areas of life leading to better health
seems optimistic. The ability to transfer skills
learned during an empowering process may
contribute to greater power in another life
domain, but there is no particular reason why the
psychological state should transfer. Also, once a
certain level of psychological empowerment is
achieved there is no reason to expect that it
should remain at that level.
With regard to community empowerment, it
seems possible that a group may be empowered
on one issue, but not another. Therefore, the
degree of empowerment may vary depending on
the issue being considered. This suggests that
community empowerment is topic specific. The
more issues in which a given group has influence
or control of resources, the more powerful that
group or community is likely to be. However,
circumstances may change such that the group
experiences a set-back, even though the level of
resource control achieved is unaltered. Groups
that pay attention to group maintenance issues
and sub-production systems (achievement of
tasks and objectives) increase their prospects of
longer-term viability (Prestby and Wandersman.
1985).
Special populations?
Different sub-groups, such as children (Kalnins ei
al., 1992), isolated rural communities (Hughes,
1987; Jenkins, 1991) and the chronically poor
and homeless (Winkle and Ward-Chene, 1992),
are particularly powerless or dependent on others
and so present significant barriers for community
empowerment. On the one hand, these are exactly
the groups with the largest empowerment deficit,
but also the groups with the most barriers to
empowerment. Such special populations may
require more active encouragement to work
towards psychological and community empower
ment, by establishing frameworks that at least set
the process in motion, and support it to some
degree (Jenkins, 1991).

What is the role of the health promoter?
‘Enabling’ people to increase control over their
health suggests some action on behalf of the
health professional. But ‘taking over' any com
munity development activity is the antithesis of
any empowering process (Batten, 1967). The

major contribution of health promoters is, then,
one of facilitation not direction. Health profes
sionals might contribute to the process by en
couraging and supporting community initiatives,
and the establishment of infrastructure and
systems which promote political activity. Efforts
within mediating structures, perhaps in a mentor
ing role or by building membership or mainten
ance activities, while not reported as the most
personally rewarding of tasks (Revenson and
Cassel. 1991) may contribute a great deal. Profes
sionally initiated projects may become empower
ing if communities or groups can organize them
selves and act politically to take control of the
effort.

CONCI.ISIONS
Several proposals have been asserted in this
paper. They are summarized here.

1. There is an important distinction between
psychological empowerment and community
empowerment. Psychological empowerment
is a feeling of greater control over their own
lives which individuals experience through
group membership, and may occur without
participation in collective political action.
Community empowerment includes a raised
level of psychological empowerment among
the community members, a political action
component in which members have actively
participated, and the achievement of some
redistribution of resources favorable to the
community or group in question.
2. Both psychological and community empower
ment are an outcome, although processes of
personal and community development oper
ate simultaneously to contribute to the
attainment of a psychological sense of
empowerment, and participation in collective
political action.

3. An increase in the control over resources (the
attainment of actual power) or a positive
change in the socio-political environment,
plus an increase in the reported level of
psychological empowerment are the appropri
ate end-points for evaluating an empower
ment program.
4. Community empowerment is a group phenomenon and does not refer to individuals.

5. Community empowerment through the syn
ergy of its critical components is related to
physical health in a non-specific way.

6. A change in the level of psychological em
powerment or control over resources for one
issue is unlikely to transfer to other areas.
Therefore, both psychological and community
empowerment are topic specific.

For work in the area of community empower
ment to proceed, common use of terms and
language would make communication easier.
Common understanding of the theoretical back
ground of the construct, keeping clear the distinc
tion between psychological and community
empowerment, and including all the critical com
ponents of community empowerment when using
the concept might avoid loose usage of the term.
Consideration of the disciplinary history of con
cepts used in health promotion might assist
common understanding (Bunton and Macdonald,
1992; Nutbeam, 1986).
Better quantification of the psychological
empowerment construct and means of assessing
changes in the socio-political environment should
be a high priority for health promotion research.
Better quantification would also allow better
study of the relation of empowerment to health
measures. Longitudinal studies are also needed,
looking not only at end-points, but at the process
and elements necessary for achieving community
empowerment. Funding agencies will need to be
convinced of this necessity.

■

.'•■J:
■

• v.
-/r

..

.

.

ACKNOWLEDGEMENTS

The author would like to acknowledge the helpful
discussions and comments regarding earlier
drafts of this paper made by John Finnegan and
Kim Miner.

i;; 31- ~

Address for correspondence-.
Christopher Rissel
Division of Epidemiology
School of Public Health
University of Minnesota
Suite 300
1300 South Second Street
Minneapolis
MN 55454-1015
USA

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46

C. Rissel

REFERENCES
Auer, J. (1989) Assessing environmental health: some
problems and strategies. Community Health Studies, 13,
441—447.
.
Bachrach, K. M. and Zautra, A. J. (1985) Coping with a
community stressor, the threat of a hazardous waste facility.
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5

''

Co^ H-O-So
health promotion international

Vol. 7. No. 3
Printed in Great Britain

© Oxford University Press 1992

Health promotion and environmental management:
a partnership for the future
and Environmental Studies, Australian National University, Canberra, Australia

JAN E. RITCHIE and ARIE ROTEM
School of Medical Education, World Health Organization, Regional Training C entrefor
Development, University of New South Wales, Australia

'

'
i

J
i

SUMMARY
Health Promotion as a professional practice is facing its
third major challenge this century. To jhejnfectious
diseases of the past and the lifestyle risEs of the present
~hdve been added the global environmental hazards oj
the future.
Each wave of health risk has three things in common.
The first is that ill-health results from a change tn the
relationship between the environment and society. The
fecond is that the ill-health so caused falls predomin
antly on already disadvantaged groups tn the comnumitv. Third, in each case there is a time lag of two or
more decades between recognition of the fresh risks to
health and effective professional response. The chai-

a

lenge today is to shorten the lead time for responding to
the third phase, the degradation of the global environ
ment. This will give a radical reorientation to the field oj
health prombtion, which has traditionally safe guarded
the health of people from environmental change, not
vice versa.
.
The reorientation of health promotion is discussed tn
terms of the contributions which health promotion can
make to environmental management. The options for
managing environmental change are identified as
protection, prevention, resilience and adaptation. These
strategies are already in use in the different branches of
health promotion.

Kcv words: sustainable environmental management; health promotion; intersectoral collaboration

Thomas McKeown’s 1976 paper, ‘The Role of
Medicine—Dream, Mirage or Nemesis?,
expanded subsequently into a book of the same
title (1979), was a milestone for health promotion
and public health. Health promotion of the
current era could be said to have been ushered in
with this paper which reflected commentaries
from Montaigne to Illich, questioning the central
role of medicine in the improvement of health.
McKeown reviewed the evidence that public and
professional attention to changing living con
ditions—the interaction between social and
physical environments—was the principle
determinant of the public’s health and not tech
nical interventions by medical experts.
McKeown documented the decline of the

nineteenth-century plagues, tuberculosis, typhoid
and cholera in Europe, as due to improvements in
housing, hygiene and nutrition, predating the use
of antibiotics and mass screening by decades. He
established that the successful public health inter
ventions were those which improved the physical
and social environment, under the supervision of
engineers, local councils and school teachers, and
were not the work of the health services.
The efforts of health services in industrialized
countries to check the nineteenth-century wave of
infectious diseases, such as the mass use of
immunization and chest x-rays, came only after
the main health improvements had been
achieved. These preventive interventions ad
vanced the health status of the population in a

219

'>

- wMO

220

V. A. Brown et al.
Health promotion and environmental management

considerable Figure 1 shows the major turn7ng
^i n?ing death ra,es UP to the early
industrial revolution, where people crowded into
the new cities without clean water or sanitation
d
?Ve
in the 1870s O’6"61- housing
faM at the turn of the centu™
(hotter d*et and personal hygiene) (Morris, 1957)
KC rWn/ 1-976 revieW of the reasons for the
decline of infectious diseases in the industrialized

health risks m western countries this century the
so-called ‘diseases of affluence’, had already made
dieir appearance during the mid 1930s. The early
male deaths from cardiovascular disease condTet'and0
thr6e deCadeS before changes in
diet and exercise were accepted as appropriate

treatments by a public health generation trained

Death Rates
per 1000
living at
55 - 65 yrs

Death Rates
per 1000
living at
55 - 65 yrs

20

MALES

30

15

15

■FEMALES

10

10

1940

1950

196C

1930

1940

1950

1960

5

MIDDLE YEAR OF FIVE-YEAR PERIOD

Mortality in middle age (55-65) from 1930 to 1960;
the contribufion of ischaemic heart disease and lung-cancer
(England and Wales). From Registrar General.

►

Fig. 2: Details of British Middle Age Mortality 1930-60 (from Morris 1957)

25
20 -

FEMALES
20

15 -

o
dl
10 10

5 L1850

I860

1870

1880

1890

1900

1910

1920

1930

TEN YEAR INTERVALS

1940

1950

1960

— 5
1970

F«g. 1: Bntish middle age mortality all causes 1860-1960 (from Morris 1957)

o?.

20

FEMALES

1930

0

I

25

5

25

o
co

30

. MALES.
MALES

Five-year
Moving average
log scale

5<

ISCHAEMIC HEART DISEASE
AND CANCER OF
RESPIRATORY SYSTEM

30
25

w

AUGAUSES..LESS.............

ALL CAUSES

dnvers physica! inactivity in relation to heart
disease (Morns et al. ,1966) confirmed that it was
Jelated^Th • Unh.e?lth>'. Phonal behaviours
re/ated to their social environments (Milio, 1976)
the?97P0rs tha^ bf6 heahh
II Was not
the 1970s that public access to this knowledge led
some sections of the population to change8their
a/
their l*fesPan (Dobson et
a/., 1985) (Figure 3). It was the 1980s before it
became clear that it was the better educated
members of the population who were able to
make use of the information.
In all the industrialized countries, lower income
mfntPS
'I01 Shared in the health improve
ments that changes in lifestyle choices have
brought to the well-to-do (Illsley, 1990). The rise
of four years in longevity in developed countries

221

-rf-

between 1975 and 1985 proved on closer exam
ination to be ten years for the highest income
groups and nearly zero for the lowest (Mackenbach and Maas, 1989). The Black Report in
Britain (Townsend and Davidson, 1982),
together with studies in other developed coun
tries (Illsley, 1990) and developing countries
(Sanders and Carver, 1985), have identified lower
income groups as having higher rates of disease
and early death in all regions of the world.
There are now warnings of a fresh wave of
health risks, this time from global environmental
degradation _ (Polunin, 1988) leading to, and
exacerbating local community problems. These
risks were first predicted as long ago as the early
1970s (Sellers and Meadows, 1975; National
Academy of Sciences, 1976). The health changes
already range from increased rate of malignant
skin melanomas from increased ultra violet radia
tion (Giles etal., 1989; Marks, 1989) to ill-health

effects from toxic industrial waste (Last, 1990).
The latter risk will fall more heavily on the lower
socioeconomic groups, since these are the groups
living on the expanding fringes of modern cities or
on cheap industrial land.
Three lessons for health promotion’s next wave
emerge from McKeown’s discussion and the
experience of health promotion in the subsequent
three decades. They are:
• that there is an integral relationship between
people’s health and their environment, to the
extent that confronting the actual infective pr_
causative agents of disease is of secondary
importance to changing the social and physical'
environmental conditions which permit the
onset of a disease;
• that vulnerability to new waves of health risk is
greater for the economically disadvantaged in
every community in the industrialized and

” Wlii
'■ u JSShi

IBWS1!

222

Health promotion and environmental management

K A. Brown el al.

320

300

I tww -'opo

INDUSTRIAL REVOLUTION • INFECTIOUS DISEASES

2 1930- 1870:

cholera
diptneria

water

sewerage

tuberculosn

crowding

hygiene
immunisal ion

ECONOMIC DEVELOPMENT - WAYS OF LIVING
head disease
lung cancer

260

road smashes

3. 1970-7:

220

200

1970

1971

1972

1973

1974

1975

1976

1977

Mortality by occupational group, age standardised
From Australian Bureau of Statistics
Fig. 3: Mortality for Australian Males from Ischaemic Heart Disease 1969-78 (from Dobson el al. 1985)

The consistent pattern of changes in social and
physical environment leading to new waves of
disease is illustrated in Figure 4. A simplified
summary of the three waves of health risk during
the last century and a half is aligned beside the
time span between their diagnosis and successful
prevention. With the early industrial revolution
came crowding and overwork, which allowed

diet, exercise

education

drug use
built environment

social equity
community
development

SUSTAINABLE DEVELOPMENT - GLOBAL STRESS

melanoma

UV radation

cul energy use
by 30%

respiratory
diseases.
cancers

climate change
toxic wastes

control wastes

stress

land degradalion

integrated
environmental
management

co,

1978

YEAR

newly industrialising worlds, so that improve- ‘
ment in living conditions becomes, by defini
tion, a health promotion strategy; and
• that there is a history of a lead time of over two
decades before the recognition of each new
form of health risk, with a further decade at
least before effective social response, and yet
another decade before professional action.
This is of special significance in the case of
global environmental change, which brings a
shift in public and professional consciousness
of what exactly constitutes a risk to health and a
very long lead time before effects are felt.

PREVENTION

HSEASE

280

240

SOURCE

PHASE
Diagno^eChang*

infectious disease to spread unchecked. With the
economic development that arose out of the
depression of the 1930s came the so-called,
‘diseases of affluence’ which are now the diseases
of poverty within affluent societies. With increas
ing economic development, the third wave of
global change affecting our total environment is
now being recognized, calling for a new approach
balancing environmental .and economic develop
ment, now labelled sustainable development.
Each phase in turn has brought benefit to human
ity in terms of quality of life, but with the benefits
have come related forms of disease. The lessons
of the time lag for health promotion are clear for
the first two waves of disease. It remains to apply
the lessons learnt to the currently emerging third
phase, risks to the global environment.

The first lesson: the relationship between the
environment and health
McKeown’s observation of the initial lack of
medical response to new health risks suggests that

Fig. 4: Environment-public health: timescales of
change 1850-2000
it is difficult for the health professions to evaluate
changes in the health environment. They are more
accustomed to diagnosing existing disease states
and tend to miss emerging patterns of ill-health.
Health-related diagnosis of the environment
requires a capacity to monitor both social and
physical dimensions. Illnesses in the western
world have arisen principally from the physical
environment in the first quarter of the century, the
social environment for the next two quarters and
now from global environmental change. Each
requires not only a fresh diagnosis but also a dif
ferent form of response.
Intervention in the physical and social environ
ment. before and not after the damage is done, has
always been a characteristic of successful health
promotion. Figure 5 shows how this relationship
still holds at a time when the risks are to the
environment itself. On_a continuum for optimum
health development on the one hand, to rehabil
itation on the other (Brown, 1985), actions to
preserve health and treat illness are compared
with actions to preserve the environment. Water
and energy use are the two health risks taken as
examples. The range of interventions on behalf of
either health or environment highlights the high
cost of failing to act before the event. The results
also reveal the many opportunities to collaborate

223

on the twin goals of prevention of disease and
promotion of a healthy environment.
The two examples serve to illustrate the inade
quacy of purely preventive, short term action for
any health risk (the central column in Figure 3),
but particularly the new style environmental
threats to health. The figure also illustrates the
risk that disease treatment and environmental,
treatment may put health and environment
initiatives in opposition to one another. This actu
ally occurs in the events described on the right
hand side of the figure. In the case of clean water
(an indicator of both environmental and human
health) when the water is at risk of organic pollu
tion, we use chlorine in a preventive way. How
ever, chlorine also creates biologically dead rivers
and its production adds to the hole in the ozone
layer. In the second example any initiative which
both reduces energy production and increases the
use of human energy (e.g. walking instead of driv
ing) is a double benefit. There is also considerable
potential for mutual support and reinforcement
between pro-active social development initiatives
for health and environment respectively (events
on the left-hand side of the figure).
Health promotion already has the capacity to
address local problems from a global perspective.
Small-pox, diarrhoeal disease and iodine defici
ency have been the theme of World Health
Organization (WHO) co-ordinated global
management programmes which could well pro
vide prototypes for global management of
dangerous wastes or high energy use (WHO,
1992). Thinking globally and acting locally is not
a new initiative for health promotion; nor is
longer term planning.
The second lesson: the relationship between
equity and health
The second lesson from the history of public
health is the greater vulnerability of the lowest
social group in any community to the health risks
of that particular era (Sanders and Carver, 1985;
Whitehead. 1988; Illsley, 1990). In cases of the
converging risks from environmental change such
as acid rain, higher radiation through the pierced
ozone layer and accumulated toxic wastes (Polu
nin, 1988), the lower educated, lower income
group of any community, already in worse health,
are bearing a disproportionate load (Mackenback
and Maas, 1989). This is self-evident in develop
ing countries. The flooded estuaries of Bangla
desh. the helplessness of the Bhopal victims of the
chemical plant explosion are some examples. An

F
? ""W

iiiii

I
• 3

Health promolion and environmental management

224

EARLY
TREATMENT

SOCIAL
CHANGE

UFESVtLE
CHANGE

PREVENTIVE
MEDICINE

primary

secondary

primary tertiary
secondary
heath promotion diseaae

health promotion practitioners since at least 1985
(Research Unit in Health and Behavioural
Change, 1989).

REHABILITATION

tertiary prevention

EXAMPLE 1. WATER

Health risk: Dystentery

$

safe water
supply

drink clean
water

water standards

chlonne
fluoride

filtered supplies

tax
industry

high temp
inclinerator

clean up
river

eat less,
exercise more

medication

surgery

Environmental risk: Polluted river

Integrated
catchment
management

reduce, recycle
wastes

EXAMPLE 2. ENERGY

Health risk: Heart disease
increased use of
human energy

Change total
lifestyle

Environmental risk: Greenhouse effect

-5

hl
US

225

V. A. Brown et al.

increased use of
non-fossil fuels

increase fuel
efficiency

tax petrol

limit cars

? global
warming

GLOBAL
ACTION

LOCAL
ACTION

PREVENTIVE
LEGISLATION

PROTECTIVE
ACTION

CLEAN-UP

Fig. 5: Environmental action and the public health continuum

earthquake in Newcastle, Australia, claims 13
lives; in Afghanistan, 200 000. The serious long
term risk to environmental balance of the Sahel
desert, the fallen Brazilian forests and degraded
soils and the Chinese industrial revolution must
be balanced in those countries against threats to
human health and survival.
Health promotion, environmental manage
ment and issues of local and global equity are
almost indistinguishable in newly industrializing
countries. It was with something of a shock, in the
1980s, that the long-developed world recognized
the same rblationship held for them. Industri-

-:".HMlli|!lJUMBI ill LU 11,1]T.7~~ -

alized, democratic and so-called egalitarian coun
tries also have groups of citizens with illnesses
arising from the condition of their social and
physical environments. This does not yet seem to
be generally recognized by those contributing to
public-health policy. For example, the reports of
the Australian National Health and Medical
Research Council reflect that the principal con
cerns are infectious agents and cardiovascular
diseases, with only a dawning recognition of the
effects of the global environment on health from
1990. Yet the role of the environment in health
has been accepted and acted upon by modern

The third lesson: long time frames
The third lesson from history concerns the long
lead time between recognition of a hazard, and
effective avoidance action. Figure 4 offers a
perspective on this time scale, covering 18502000 now well documented by epidemiology
(Morris. 1957; Hetzel, 1980). We now have
measures of the extent of the ozone hole (Brown
and Flavin, 1988) and the rise in average global
lemperature, and a debate over ocean levels
(Keepin and Kats, 1988). Mortality from malig
nant melanoma in Tasmania, the part of Australia
closest to the Antarctic ozone hole, has increased
22% in males and 17% in females (Giles el al.,
1989) between 1930 and 1987.
Global temperatures have risen slightly. Sea
water rises are detectable but unpredictable.
Toxic waste dump sites are being used for urban
development as, for instance, Kingston in
Queensland. Australia's inner city residential
areas lie in close proximity to intractable waste
storage facilities in Sydney and Melbourne. We
are already in our next phase of health risk. Mean
while, local, national and international discus
sions on appropriate action are running within the
traditional lengthy time frame between diagnosis
and effective response. The phasing out of chloro
fluorocarbons which disturb the ozone layer is at
least ten years away. Reduction of energy use,
which could halt climate change, is barely on the
global negotiating table, although Australia has a
20% reduction policy. Nations are just commenc
ing sustainable development programmes. In
Australia, local governments, where decisions on
environmental policy will be managed, are begin
ning to ask what it will mean for them.
June 1992_saw a major United Nations con
ference on Environment and Development.
Health was not a separate item on the agenda.
Responses to health risk from environmental
changes thus cannot be taken for granted. In the
case of environmental change, waiting to deal
with the effects may condemn a generation. It
could be suggested that the present adult Euro
pean population may be the healthiest the human
species will ever know, with a life expectancy of
over 80 years sandwiched between the defeat of
infectious and lifestyle diseases, and the risk of
projected environmental hazards.
The need to act on the sources of the problem.

'

• -T'

: >■

rather than the effects, is even more important for
environmental than for social health risks. On
behalf of future generations, we cannot afford to
add to the many existing environmental time
bombs, such as chemically contaminated indus
trial sites (Yakowitz, 1985), or the 47 nuclear
warheads on the floor of the world s oceans
(Renner, 1989).

Response strategies: the role of environmental
health
Environmental Health could be expected to be in
the forefront of the response to this new environ
mental challenge. The task is, after aU^ the same
task that public health faced in the, nineteenth
century, when it developed and monitored
standards for food, air, water, waste disposal, and
safety. The 19^ Bibliographic: Index for En
vironmental Health now lists over 153 headings.
within those categories. There is, however, no
record in the Index under Environmental Health
of work on the new environmental challenges tQ„.
public'healtK. Natural disasters, climate and
meteorology, conservation of natural resources
and conservation of energy resources are listed,
but under the general rubric of public health.
Examination of the past four years’ issues of the
Journal of Environmental Health produces the
same result: concentration on the standards, tests, legislation and controls related to. long.-estab-.
lished environmental hazards. Many controls
have existed unimplemented for decades, at least
in Australia. For example, radiation standards in
industry, radon levels in houses, lead levels in the
atmosphere and asbestos in domestic air have
been ignored until this present decade. The
history of each of these can be traced in the
Reports of the Australian National Health and
Medical Research Council 1980-1990, showing
the now-familiar time lag between their identifica
tion as a health hazard and local response.
This regulatory aspect of environmental health
falls as much on the curative and rehabilitative
end of the public health continuum as the pre
ventive end (Figure 5). The awareness of tests to
be taken, or penalties to be incurred, may inhibit a
polluter, but does little to address the reason for
polluting. Standards are set through evaluating
the effects, usually dose related, of a pollutant on
humans. Such tests do not usually include the
effects of pollutants on the biosphere, although
they could do so. Standards also now need to
include threshold effects beyond which it is diffi
cult for humans or the environment to recover.

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The World Health Organization (WHO) has
monitoring policies and strategies against comrec<
_ ’
:ognized
this gap by reorganizing its Environprehensive social and physical baseline indir
•_
,
cators;
mental Health Division into four sections, rural
and urban development, toxic chemicals, food
• strengthening community action, recognizing
safety and control of environmental health ; that lasting change will not occur without comhazards. Expert panels will also explore health in ! munity contributions to planning and action and
relation to four themes, the ‘dev
_ elopme
____ntal dir
i that community groups most at risk may need
ing forces of energy, urbanization,
■ -1—'i--- food
r--j and
quite different interventions and support from the
nirTT^ inom
more privileged groups;
industry’(WHO,
1988).
The new phase of response to environmental
• developing individuals' skills in applying health
health hazards appears to be just beginning. The . knowledge and undertaking health advocacy;
country which in 1984 gave us the Canadian
• reonenmringservzcestowardspromotingwellHealth Field Concept, defining health as the outh-t™
— :n
—- and jdisease
;-----being, «>«■
as welln »«•
as treating
illness
cpme pfhuman biology, lifestyle, health services
(WHO Ottawa Charter^ 1 £86).
and^nvdrpiunept (Lalonde, 1974), is now provid
As yet, there is as little recognition of global
ing some of the first analyses of global environ
environmental problems in the health promotion
mental hazards to appear in the public health
literature as there is in the Journal of Environ
literature. Labonte of the Ontario Public Health
mental Health. A literature search of health
Association, has formulated the sustainable., de
promotion programmes over the past five years
velopment principles.fpr public health quoted in
raised 2500 articles on health promotion and
Figure 5 (Labonte, 1991). Hancock (1989) writ
health education programmes (Medline, ERIC
ing on the need to integrate ‘Health, Economics,
and HEAPS 1986-91). This reduced to 15 when
Enyironment’, and Last (1990), predicting that
crossmatched with the word environment. Of
global environmental issues will become the
those six were concerned with the environmental
centre of modem public health practice, have
setting of indigenous peoples (Canadian Indian
joined WHO in pointing a new direction for
and Aboriginal), six with ‘curative’ environmental
environmental health.
health, and three with the broader social environ
ment in an urban setting. One of those referred to
Response strategies: the new public health
local and global issues (Figure 6).
Health promotion programmes based on com
Possible conclusions from Figure 6 are that
munity education and social change have been
either
running for over ten years. Examples are the pro
(i) there is no valid professional connection
grams in North Karelia (Puska et al., 1985),
between health promotion and global en
Stanford (Farquhar, 1984), and Northern New
vironmental issues, or
South Wales (Tyler and Frape, 1980). Changes in
(ii) the McKeown time lag effect is in good work
social conditions, based on the at-risk community
ing order. This second conclusion would
and working to an explicit evaluable framework,

• integrating policy on all social issues, recogniz
ing that education, housing and finance policies
are as important contributors to health as health' care policy;
■ • creating supporting environments, through

THEME

mean accepting that, yet again, evidence of
new types of health risk are preceding their
recognition by health professionals.
The history of health promotion and public health
suggest that the second is the case.
Response strategy: sustainable development
Sustainabje Development, is. the title commonly
used for the principal strategy for dealing with
environmental issues. The generally accepted
definition of sustainable development comes
from the 1986 Report of the World Commission
of Environment and Development (WCED): ‘sus;
tainable development entails meeting the needs of
the present gen.eration without compromising the
ability of future generations to meet their own
needs’^VCED, 1986).
In pursuit of a research paradigm which joins
health promotion and sustainable development, it
is useful to compare sets of principles for sustain
able development from environment lobby
groups (Hare, 1990) and a Canadian public
health practitioner (Labonte, 1991). The two sets
of principles are ranged side-by-side in Figure 7.
Although from different continents and profes
sions, they are strikingly similar. Considerations

FOR ENVIRONMENT'

FOR PUBLIC HEALTH"

ecological integrity
and biodiversity

ecological principles
and sustaining diversity

intergenerational equity

planning across generations

community participation

sustaining communities

social equity

empowering equally

natural capital with
sustainable income

producing fairly and healthily

global perspectives

shrinking global and national
inequities

limits on natural resource use

repairing, recycling, replacing,
reducing

qualitative development

nurturing the intangibles

pricing environmental
values and natural resources

internalising all costs

precautionary principles

social health principles

NO. OF RECORDS

Health Promotion Programs

2177

Hearth Education Programs

3710

Environment + Program

15

‘ Indigenous People

6

’ Urban Social

6

' Local & Global

1

combined Australian
conservation groups.
Hare (1990)

Fig. 6: ERIC, MEDLINE, HEAPS literature searches
for 1984-89

Canadian public health
consultant. Labonte
(1991)

Fig. 7: Principles of sustainable development

of equity across and within generations, limita
tions on resource use, valuing intangibles and the
importance of community are consistent themes
in both sets of principles; and consistent also with
the direction of the New Public Health. The
emphasis in both is on resilience and adaptability.
There are recommendations on types of behavi
our and values; but little emphasis on regulations
or coercion.
In looking back to Figure 5, environment and .
health promotion strategies were aligned together
on*thehealth promotion eridTof the prevenflYp
continuum, Sm 'differed considerably at the,
treatmem-rehab^iiQnZfindL This congruence
with respect to promotion of health in people and
in environment is also reflected in the two sets of
principles in Figure 7. Sustainable development is
being treated as an economic strategy in many
global national politics and policies (Pearce e/ al.,
1989). Yet, as indicated by Figures 5 and 7, sus
tainable development is integral to health promo
tion, which has much to offer the debate.
There remains the question of whether com
bined action on health and environment will be
readily acceptable to the health and environment
professions and the community. This question
was pul to the test by the authors in a small study
in which 75 students in health and in environment
courses were asked their interpretation of
messages and slogans about health and about
environment. Respondents from both groups
were far more likely to identify the messages as
needing action on health and environment
together, rather than on either alone. In a study of
low-income workers in relation to their know
ledge of health issues, a majority reported that
they would act on their health only in the context
of their whole social and physical environment
and not on health issues alone (Ritchie et al.,
1990) . Such local studies indicate that, in
Australia at least, an active connection between
health and environment issues is already being
made by both professionals in training and the
general population.
IMPLICATIONS

Searches of the research literature on environ
mental issues, environmental health and health
promotion revealed very little formal work being
done in the area of overlap between the three. Yet
we have seen that all three are working on, and are
generally regarded by the public as working on,

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Health promotion and en vironmental management 227

have been shown to reduce a health risk such as
smoking or high fat diet for individuals and to
alter population behaviour. Control of increase in
AIDS in Australia is an example of the success of
this approach (Ross et al., 1989).
Experience in using social change as a health
promotion strategy has much to offer environ
mental managers as well. The New Public.Health,
wijh its* glpbaLjietwo'rk in the Healthy Cities
Project, is based on a charter for a five-part social
change strategy;..................... *

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Heulth promotion and environmental management 229

228

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V. A. Brown et al.

the same issues. There are moves in most Western
countries to develop national sustainable de
velopment programmes. It is important, there
fore, for public health policy makers, research
workers and practitioners to explore what this
may mean for them.
With sustainable development as the common
theme, combined health and environmental pro
grammes can be monitored along two dimen
sions, which together form a diagnostic grid.
Mqyernent from an after-the-event treatment
orientation towards promotion of both health and
ecological balance is central to the concept of
sustainable development. This is the case for
those who work in either health promotion or
environmental management. The shift in
response away from short term or crisis responses
to instigating long term change is inherent in both
the new public health and sustainable principles.
Figure 8 presents the two dimensions, acting on
causes and effects, and acting for the present and
the future, as a grid against which policy, practice
or research into health/environment issues can be
identified. The grid is applied to the greenhouse

LONG TERM, SUSTAINABLE
action for lha futura

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rapulaliona. acdOantt and
amerpancy aarvicaa

SHORT TERM. IMMEDIATE
action tor lha praaant

• Note: all pomts on me gnd appropriate under some circumstances

Fig. 8: Health environments and sustainable develop
ment—a diagnostic grid* Example: response to the
greenhouse effect

effect as an example of a joint health/environment
issue.
Sustainable development and the new public
health are each designed for maximum health
development for economy, environment and
people. Both have a future orientation and act on
causes not effects.
Pro-active problem solving and learning
approaches will be a feature of the first quarter of
this grid, in which social change is an accepted
strategy, and adaptability is the objective. Useful
here will be the new resource economics which
allocates a value to intangibles such as health and
environment (Daly and Cobb, 1989); mediation
and negotiation rather than adversarial law; and
acceptance of the need for biodiversity as well as
for monocultures. Work in this first quadrant
would need to be open to the new, the complex
and the ambiguous, since it is dealing with a future
in which change itself is certain. The nature of the
change is not completely known.
The horizontal axis of Figure 8 is consistent
with the health development continuum in
Figure 5. Thus the treatment pole of the health
continuum in Figure 5 reflects an emphasis on
current practice, and the provision of services, as
does the right-hand side of the proposed environ
mental management grid. The left-hand side ol
the grid is developmental, dealing with planned
social and environmental change. This requires
an ability to manage a change process as an inte
grated system. For instance, a major change
already in train will be the 20% reduction in
Australian carbon dioxide emissions in late 1990
in order to reduce the effect of global warming.
On the right-hand side of the grid, 'emergency’
and short term responses provide protective
measures: disaster programmes, strengthened
coastal zoning, sunscreens, etc. Active, health
promoting solutions for resilience or adaptation
on the left-hand side of the grid involve all five
strategies of the new public health. Resilience is a
matter of encouraging appropriate existing types
of health development programmes. Adaptation
implies being prepared to develop quite new
types of programme to meet new conditions
Strategies in quadrant 3 include reducing harm
from higher water levels and erratic storms. Thc\
include taxes on use of electricity and oil in trans
port and industry.
For all four options for action, there are exist
ing strategies. at least in theory if not yet in general
practice. Strategies already successfully trialed in
a range of industrialized countries include sup-

port for more efficient public transport; voluntary
reduction of energy use in exchange for technical
assistance with energy efficiency in homes and
industry; increased use of human energy (a plus
for heart disease); community groups offering
planning options, such as traffic calming, and
purchasing and transport cooperatives (CART,
1988). It is policy, research and practice in the
first quadrant which will develop and test applications of the sustainable development principles
listed in Figure 7. Even after testing, there needs
to be a willingness for policy makers, research
workers and practitioners to put the new ideas
into their standard repertoire. This will call for
consideration of appropriate management skills
in each area.
The four quadrants for sustainable healthy
development match the four management styles
for long-term sustainability proposed by Brinker
hoff and Goldsmith (1990) They label the styles
proactive, adaptive, reactive and mechanical,
respectively; but their description matches the
adaptability, resilience, prevention and protec
tion option of environmental management in
Figure 8.
The characteristics of action within the adapt
able, sustainable development quadrant can be
summarized as follows:

• acting on causes of a problem (not only the
effects);
• future-oriented (acting before the threatened
event);
• responding to uncertainty and ambiguity in
risks from environmental change;
• integrated solutions from all sources including
1 community, science, professions, and administra
tors;

• recognizing socially disadvantaged groups as
especially vulnerable;
• translating global issues into management of
the local environment
In developing sustainability, the issues selected,
the type of strategy chosen, and the style of
management of (he process are all important ele
ments in adequate action. The new public health
offers a suitable social change strategy. Sustain
able development provides a rationale for de
veloping consistent strategies in health and in
environment. Methods which allow lor the inte
gration of multidisciplinary evidence, and com
munity involvement in the management oi change
have been developing over the past decade
(Rotem. 1989). There remains the need to apply

these initiatives in public health policy, practice
and research, not only to aid in the overall
achievement of environmental sustainability, but
as a watchdog in protecting the public health
against the structural changes arising from sus
tainable development.
The environmental changes are certain. The
level of risk, or even what forms the risks might
take, are still very much matters of debate. Yet, as
in previous cases of new patterns of morbidity
and mortality, waiting until we can be certain
costs a generation of lives. The questions and the
possible answers need to be developed now. The
challenge to think globally on environmental
issues, and act locally through health promotion
programmes is already with us. Health promotion
now provides quality of life programmes, social
change strategies and public education, all key
strategies for environmental management.
Responsibility for linking health and environment
has been the basis of success for health promotion
in the past. It is surely the way of the future.
Address for correspondence-.
Valerie A. Brown
Centre for Resource and Environmental Studies
Australian National University
GPO Box 4
Canberra ACT 2601
Australia

REFERENCES
Brinkerhoff. D. and Goldsmith. A. (1990) Institutional
Sustainability and Lessons from Agriculture: Implications
For Health Development. World Health Organization
Division of Strengthening Health Services, Geneva.
Brown. L. R. and Flavin. C. (1988) The earth s vital signs. In
State of the World 1988. Norton, New York. pp. 3-21.
Brown. V. (1985) Towards an epidemiology of health: A basis
for planning community health programs. Health Policy and
Education, 4: 331-334.
Citizens Against Road I ransport (1988)1 raffic Calming: The
solution to Route 20 and a new vision for Brisbane. In
Brisbane Traffic Study. Brisbane City Council, Brisbane.
Daly. H. E. and Cobb. J. B. (1989) For the Common Good.
Redirecting the Economy toward Community, the Environ
ment, and a Sustainable Future. Beacon Press, Boston.
Dobson. A. J.. Gibberd, R. W.. Leeder. S. R. and O'Connell.
D. L. (1985) Occupational differences in ischemic heart
disease mortality and risk factors in Australia. American
Journal of Epidemiology, 122, 283-290.
Doll. R. and Hill. A. B. (1962) Smoking and Health. Report of
the Royal College of Physicians, London.
ERIC (EducationalResearch Information Committee) (/966-)
U.S. Department of Education. Office of Educational
Research and Improvement. Washington.

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V. A. Brown et al.

Vol. 7, No. 3
Printed in Great Britain

health promotion international

0 Oxford University Press 1992

Farquhar, J., Fortmann, S., Maccoby, N. et al. (1984) The
Stanford five city project: an overview. In Matarazzo, J.,
Weiss, S., Nerd, J. el al. (eds) Behavioural Health: A
Handbook ofHealth Enhancement and Disease Prevention.
John Wiley, New York.
Guiles, G., Dwyer, T., Coates, M., Bonnett, A. and Ring, I.
(1989) Trends in skin cancer in Australia: an overview of
available data. In Refshauge, W. (ed.) Transactions of the
Menzies Foundation Vol. 15: Ozone Layer and health. The
Menzies Foundation Melbourne, pp. 143-148.
Hancock, T. (1989) Health-Economics-Environment. Pro
ceedings of a National Workshop. Health and Welfare
Canada, Ottawa.
Hare, W. L. (ed.) (1990) Ecologically Sustainable Develop
ment: A Submission to the Australian Government.
Australian Conservation Foundation, Melbourne.
HEAPS (Health Education and Promotion System) (1985-)
Ozline: Australian Information Network.
Hetzel, B. (1980) Health and Australian Society. 3rd edilion
Penguin, Ringwood.
Illsley, R. (1990) Comparative review of sources, method
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Keepin, B. and Kats, G. (December, 1988) Greenhouse warm
ing: comparative analysis of two abatement strategies.
Energy Policy, December.
Labonte, R. (1991) Econology: integrating health and sustain
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Lalonde, M. (1974) A new perspective on the health of
Canadians: the Health Field Concept. Health and Welfare,
Canada, Ottawa.
Last, J. (1990) Public health and the global environment.
Canadian Journal of Public Health, 81,3-5.
Mackenbach. J. P. and Maas, P. J. (1989) Social inequality and
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Marks, R. (1989) Freckles, moles, melanoma and the ozone
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McKeown, T. (1976) The Role ofMedicine: Dream, Mirage or
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McKeown, T. (1979) The Role ofMedicine: Dream. Mirage or
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Milio, N. (1976) A framework for prevention: changing
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Morris, J., Hagan, A., Patterson, D. and Gardner, M. (1966)
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National Academy of Sciences (1976) Halocarbons: Effects
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Polunin, N. The environmental dimension and threats to our
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Puska, P., Nissinan, A„ Salonen, J. et al. (1985) The
community-based strategy to prevent heart disease: con
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Research Unit in Health and Behavioural Change (RUHBC)
University of Edinburgh (1989) Changing the Public
Health. John Wiley, Chichester.
Ritchie, J.. Herscovitch, F. and Norfor, J.(1990) Beliefs ofblue
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Ross, M.. Freedman. R. and Brew, R. (1989) Changes in
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Rotem, A. (1988) Managing Systems for Better Health. .1
Facilitator's Guide. World Health Organization Regional
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Townsend, P. and Davidson, N. (1982) Inequalities in Health.
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(WCED) (1987) Our Common Future. Oxford University
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(1988) Promotion of Environmental Health. Global
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Washington.

Book Reviews
Life After Work: The Arrival of the Ageless Society
M. Young and T. Schuller
HarperCollins, 1991,194 pp. ISBN 0 002 15929 5 £16.00

Michael Young and Tom Schuller have collabo
rated here to push forward our understanding and
persuade us of policies to modernize the place of
older people in post-industrial society. Distin
guishing between the biological and the social
determinants of ageing, they call for root and
branch reform of social attitudes and see the
future for the old as one of potential political
radicalism with respect to the social distribution
of money and honour and opportunity.
The evidential base for their argument .s not a
large scale survey but a detailed and vivid descrip
tion of 149 men and women in Greenwich aged
50 to the official pensionable age (65 for men, 60
for women) who had left full-time employment
within the two years before 1984/5 when the field
work was carried out. Michael Young produced a
framework of interpretation in his The Metro
nomic Society: here the two authors analyse the
transition of their informants from work to ‘retire
ment’ or elderly leisure with a keen eye to the
central problem of how varied they have been in
spending their large and diminishing major
resource—time. The outcome is a fascinating
book, modest in its scientific claims, compelling in
its human descriptions, and bold in its policy
prescriptions.
The underlying question in conventional terms
is whether old age is the final shipwreck or whether
it can be a relaxed voyage towards the end of life.
Young and Schuller argue an optimistic view. Yet
they are realistic. They know the traditional folk
wisdom that the rhythms of the life-cycle have
crisp, bleak and melancholy expression in
’Solomon Grundy born on Monday, christened on
Tuesday etc’. Yet they note the medical advances
and demographic transitions and assert the pos
sibility as well as desirability of a fundamental

reform—which is nothing less than a project to rid
human society of age-stratification.
Their ambition fits the temper of the times.
Every year it becomes more plain that twentieth
century political and social movements are essen
tially experiments with the possibility of ridding
society of its traditional placement of individuals
by ascription. Legislation everywhere, from the
USA, to the EEC, to the new regimes replacing
the Soviet Union or the promise of South Africa,
outlaws the use of ascriptive allocations of
chances in life. Education, health, welfare and
jobs must be open to citizens without regard to
race, sex, religion or national origin. Young and
Schuller want to add age to these proscribed
ascriptive categories. Even pensions should no
longer be tied to age but instead to need and
preference. And school leaving ages should be
privatized with rights to education in the form of
vouchers handed out to both school and work
leavers.
Of course Young and Schuller are not the first
optimists. Peter Laslett published his A Fresh
Map ofLife in 1989, celebrating the arrival of the
Third Age. The combined message of the re
formers in that past attitudes are out of line with
future possibilities. Nevertheless, we must begin
with the fact that we inherit uncheerfulness from
past experience. Old age has meant poverty and
dependence. The poverty cycle is part of folk
wisdom. Earlier in this century the distinguished
social researcher, Rowntree concluded that
working-class children were bom in poverty,
escaped for a brief period of adolescence and
childless marriage, were dragged down again by
dependent children, made better off when the
children grew up and found jobs, and finally
declined yet again to ailing and want in old age.
231

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HEALTH EDUCATION RESEARCH
Theory & Practice

Vol. 10 no. I 1995
Pages 37-50

Self-efficacy in health promotion research and practiceconceptualization and measurement

Edward Maibach and Debra A.Murphy'
Abstract

health promotion interventions (Bandura, 1977a
1986, 1991, 1993). Self-efficacy, an underlying
"his article examines the self-efficacy construct
causal mechanism in SOT (Bandura, 1982), has also
as it relates to health promotion research and
assumed an increasingly important role in health
practice. A conceptual analysis is provided to
promotion practice and research, independent of its
identify the consequences of self-efficacy and dif
original theoretical context (Maddux and Rogers,
ferentiate it from related constructs, and an
1983; Strecher et al., 1986; Garland et al., 1988;
operational analysis is presented to identify the
Rosenstock et al., 1988; Catania et al., 1990). Self\O
relevant aspects of self-efficacy measurement
efficacy has been shown to be a causal mechanism
which include level, strength and generality.
in a wide range of health behaviors including
Various considerations for the development of
smoking cessation, weight control, exercise,
self-efficacy items including the need for
nutrition, alcohol use, contraception and AIDS
behavioral specificity, the use of formative
prevention (O’Leary, 1985; Strecher etal., 1986;
research and the wording of instructions are
Yalow and Collins, 1989; Bandura, 1991, 1992)
presented. We conclude by reiterating that there
Health promotion interventions that enhance selfare no all purpose approaches to the measurement
efficacy, in turn, foster health behavior itself (e g
of self-efficacy—self-efficacy measures are by
Gilchrist and Schinke, 1983; Kaplan etal., 1984;
necessity tailored to specific domains of function
Bernier and Avard, 1986; Deshamais et al., 1986’
ing and, in many cases, to specific populations.
Maibach et al., 1990).
Methodological rigor in the assessment of selfDespite an abundance of excellent empirical,
efficacy requires application of elicitation research
conceptual and review articles on the role of selfidentify appropriate competencies and
efficacy in health promotion, misconceptions persist
challenges, and the casting of items in standard
about the construct and its measurement. This article
ized and validated formats.
will examine the self-efficacy construct and
distinguish it from related constructs, review and
Introduction
propose self-efficacy measurement strategies, and
discuss the importance of efficacy beliefs in health
Since its inception over a decade and a half ago,
promotion research and practice.
Bandura’s social cognitive theory (SCT; formerly
Although this paper focuses on self-efficacy among
termed social learning theory) has increasingly
adults, the conceptual and measurement issues are
gained acceptance both as an explanatory model of
applicable to children as well. Standard measures of
health behavior and a guide for developing effective
the self-efficacy construct have provided evidence of
its construct validity among children (e.g. Cowen
Emory University School of Public Health, Atlanta,
et al., 1991; Schlosser and Havermans, 1992). Berry
GA 30329 and ‘UCLA Neuropsychiatric Institute, Los
and West (1993) have presented an integrative review
Angeles, CA 90024, USA
of empirical studies of cognitive self-efficacy from

© Oxford University Press

37

d

E.Maibach and D.A.Murphy
childhood through old age, and found support
throughout the lifespan for hypotheses regarding the
sources and effects of self-efficacy.

The self-efficacy construct
Self-efficacy is a pivotal construct in SCT in that it
mediates the application of knowledge and skills in
the pursuit of behavioral attainments. Self-efficacy
refers to people’s belief in their capability to organize
and execute the course of action required to deal with
prospective situations (Bandura, 1977b). Bandura
(1993) has recently expanded the domains of selfefficacy functioning to include confidence in
capability to regulate one’s motivation, thought
processes, emotional states and the social environ
ment as well as levels of behavioral attainment.
Success in most areas of human endeavor requires
commitment, resourcefulness and preseverance.
These are precisely the qualities addressed by selfefficacy. An expression of personal efficacy is an
assertion of confidence in one’s capability to
overcome the difficulties inherent in achieving a
specified level of behavioral attainment.
Self-efficacy judgments are specific to behaviors
and the situations in which they occur (Bandura,
1986, 1977a; Hofstetter et al., 1990). That is to say,
self-efficacy is defined at the behavior-situation unit
of analysis. People arc not self-efficacious in general,
rather their sense of efficacy is tied to particular
domains of functioning. Individuals express a wide
range of efficacy beliefs across a variety of domains
of functioning; people who are confident that they
can adopt a healthier diet may or may not be
confident in their capability to exercise regularly.
Moreover, situational demands determine efficacy
beliefs. One’s confidence in ability to adopt a
healthier diet, for example, is likely to be higher
when in residence at a health spa than when working
overtime in a highly stressful job.
It is important to distinguish between efficacy
beliefs and outcome expectations (Bandura, 1977b,
1984). An outcome expectation is a person’s belief
about the outcomes that result from a given behavior.
These outcomes can take the form of physical, social
or self-evaluative effects. An efficacy belief concerns

38

one’s capability to produce the behavior. People are
motivated to perform behaviors they believe will
produce desired outcomes. Efficacy beliefs mediate
this motivation, however, in that individuals can
believe a behavior will lead to desired outcomes, and
yet have no confidence that they personally can
perform the required behavior.
In SCT, self-efficacy plays a central role in
behavioral interventions for two reasons. The first
is that diverse behavioral influences (e.g. social,
normative, educational, motivational) operate, at
least in part, by bolstering beliefs in personal
efficacy. As a result, self-efficacy functions as a
mechanism of action common to many forms of
behavior change intervention. The second reason is
that efficacy beliefs are dynamic and subject to
influence; they are a product of on-going cognitive,
behavioral and communication processes. Beliefs of
personal efficacy are changeable by different modes
of influence. Enhancement of efficacy beliefs, in
turn, leads to increases in motivation for—and
success with—behavioral efforts.

The consequences of self-efficacy
The importance of efficacy belief systems is best
understood by examining the processes by which they
exert their effects on human functioning. There are
four broad processes through which efficacy beliefs
operate: choice behavior, effort expenditure and
persistence, thought patterns and emotional reactions.
Choice behavior
People make choices every day about what activities
to pursue or to avoid. Many of these decisions are
undoubtedly inconsequential, but the cumulative
effect of daily choices—especially those related to
health behaviors—determines the direction of
people’s lives, including long-term health prognosis.
Self-efficacy plays an influential role in this process
in that people tend to avoid tasks they feel exceed
their capabilities, while pursuing those they feel
competent to perform (Bandura, 1977b, 1986). For
example, smokers with low efficacy to control their
smoking behavior attempt to quit less often than those
who judge themselves more efficacious (DiClemente

I•

Self-efficacy in health promotion research and practice
Table I. Conceptual analysis of self-efficacy and related terms
Concept name

Measure of what

Uni of analysis -

Self-efficacy

belief in personal
capability

behavior-situation

Self-esteem

judgment of self worth

person

Self-confidence

strength of belief in
abilities

person

Locus of control

belief about whether
outcomes result from
behavior or external
forces

person

Generalized self-efficacy

belief in capabilities
across all behavioral
domains

person

et al., 1985). This effect of self-efficacy can help
explain why sedentary individuals are reluctant to
attempt exercise, why people with poor eating habits
are less likely to attempt dietary modification, and
why sexual risk takers may not adopt safer sex
practices.

I

Effort expenditure and persistence
Mastering new activities requires both effort and
persistence. A robust sense of efficacy motivates
people to engage themselves fully in the tasks they
undertake. For example, cardiac patients with high
exercise self-efficacy can get themselves to exercise
harder on a treadmill test than patients with weaker
efficacy (Ewart et al., 1983). Individuals who feel
highly efficacious regarding their capability are also
more persistent in the face of difficulties than those
persons with lower efficacy. For example, efficacy
regulate eating behavior predicts decreased
attrition from weight loss programs (Bernier and
Avard, 1986) and dietary efficacy predicts adherence
to dietary treatments for elevated cholesterol
(McCann et al., 1988). When mastery attempts are
thwarted (which is often the case), people of low
efficacy tend to give up or reduce their effort,
whereas those of high efficacy generally intensify
their efforts until they succeed (Brown and Inouye,
1978; Bandura and Cervone, 1983).

Thought patterns

Efficacy beliefs also affect thought patterns that can
enhance or undermine performance. These cognitive
processes take three forms:

CO

(1) Goals and aspirations—high efficacy supports
high expectations, while low efficacy causes
people to dwell on their perceived deficiencies.
(2) Visualization of positive and negative perfor
mance scenarios—high efficacy encourages
visualization of successful performances,
which, in turn, provides positive guidance for
mastery efforts.
(3) Quality of inferential thinking—high efficacy
encourages analytical thought processes in
reaction to setbacks and difficulties (Wood and
Bandura, 1989).
Emotional effects
Perceived self-efficacy also plays an influential role
in the regulation of affective states. In coping with
taxing situations, people who have a low sense of
efficacy are more vulnerable to stress and depression
(Bandura, 1986).
Perceived self-efficacy facilitates behavioral attain
ment through these four processes. These effects are
documented with extensive evidence from divergent

1

$

39

❖

E.Maibach and D. A. Murphy

(“19^
aCade™C Performances
(hchunk, 1985), career choice and development (Betz

1986)’ athJetIC

Xi

(Wur^

1986), social performance (Leary and r ;

behavlrs (D^r P'^^P0"

to provide the predicttve and explanatory advantages
of specific efficacy judgi;ments.
Locus of control

hea,th prOmotinS

cX J
(I?lClenlente. '986; O’Leary, 1985~
Strecher etal., 1986; Bandura, 1991).

generalize expectancy regarding the source nf

Conceptual analysis

te” tXder‘b,e l'°"’e”,'y

.h«

Uie self-efficacy construct is used in the healrh
promotmn literature (Strecher el al.,
may be partly due to the fact that the term 2f

S=£=
comes, whereas sei Efficacy is concerne(J

"2“

boU’ '■y "

“SXoT“"y
O\

of these constructs.

a highi; predictiveXk

esents a summary

Global self-image
Most commonly confused with self-efficacy are

Generalized self-efficacy

a~o°n7r
and self-confidence. Both of these constructs are
istrnct from self-efficacy in a number of ways Self
esteem refers to judgments of self-worth or J>e

rRoreetL° WhlCh

like Or dislike themselves

(Rosenberg and Kaplan, 1982). While self-esteem

is concerned with self-worth, self-effic^re

e COndlOons, perceived

is reasonaHe r"317

behaViOral domains- '>

is reasonable to expect that efficacy beliefs for nn^
type o acttvity will generalize to other activities that

X^?s,m,larsk,ns-In fa«’ B-d“

concerned with judgments of personal cap'bdit;
a mtj Ore; “ 3 fKrSO^"y
^'f^'cem exem

(1980) specrfy generality as a relevant aspect of

of h r3'6 eV£l °f ,nfluence on a wide spectrum

oelow). Some researchers have incorrectly inter

havioral domains, whereas self-efficacy
behSmen^ eXen 3 powerftj| influence on specific
behavtoral domains.
specihc
Like self-efficacy, self-confidence is the feeling
go^ls Z
°ne'S Wil1’ accomplish one I

KapL 1982T? 'n °ne’S effOrtS’' (R0Senber8 and

wX^rr!dwr“y

■-«-

across all stations and domains of fimctioninr
(Tipton and Worthington, 1984; Smith 1989- Want

“
“fashion
X.1distorts
? T”the“"seie Efficacy construct
n this

r-apian, 1982). However, self-confidence is uXl rn

■ tjcneral self-assessments of this type are unable

40

considerable pred^Xer“aluheaVe P™6" '0

I •

I
Self-efficacy in health promotion research and practice

Operational analysis
■llhough a great deal has been written about
^reived self-efficacy, and many studies have
vestigated relationships between efficacy beliefs
id health behavior change and maintenance (e.g.
■hambliss and Murray, 1979a,b; DiClemente, 1981;
artigan et al., 1982), very little has actually been
■ritten regarding the development of self-efficacy
ales. We will briefly describe standard features of
If-efficacy scales and provide a more detailed
scussion of self-efficacy scale development for
^Ith promotion research and practice.
evd and strength dimensions of self-efficacy
neasi
tent
ne format of self-efficacy assessment calls for
x)ple to make two judgments:
) Whether or not they can accomplish a given
performance, registered by a ‘yes’ (can
perform) or ‘no’ (cannot perform) rating.
!) Their strength of assurance that they can do it,
generally rated on a 10 (a little certain) to 100
(highly certain) point scale.

■he first judgment is repeated over a series of
.creasingly difficult performances, then the second
dgment is made only for those items answered
Tirmatively (i.e. can perform). The affirmation
idgments determine the level of perceived selfTicacy, i.e. the number of activities people judge
4ey can execute (Bandura, 1977b). Level of
srceived self-efficacy should reflect perceived
■ipabilirv as measured against task demands at
■ariou:
'els of challenge to successful perfor■lance. The second set of judgments, the strength
'f assurance scores, are averaged to determine the
rength of perceived self-efficacy. Figure 1 presents
n example of the two-judgment approach.
The performances assessed with self-efficacy items
re typically not discrete acts, but rather courses of
ction reflecting different situational demands. For
xample, level of driving self-efficacy is measured
ot by asking people if they can perform the motor
omponents of driving such as steering or reading
te traffic, buf rather by measuring their capability

to drive under increasingly more challenging
conditions (such as at night, through city traffic and
on a mountain road).
A second and more convenient approach to selfefficacy assessment incorporates the two judgments
(can/cannot do and strength of assurance) into a
single item using a 0 to 100 point scale anchored at
one end with “cannot do at all” and at the other end
with “certain I can do’’. This produces efficacy
ratings equivalent to the two question format. A ‘0’
response on the single judgment scale indicates that
a person cannot perform the task at all. This format
allows investigators to plot probability functions
between self-efficacy judgments and behavioral
enactments. As a result of this and its convenience,
it has become the most common format for assess
ment of self-efficacy.1 Figures 1 and 2 provide
examples of these two approaches to self-efficacy
assessment.
Strength of perceived self-efficacy is not necessar
ily related to choice behavior in a linear fashion
(Bandura, 1977b). A threshold of efficacy strength
may be required to even attempt a course of action;
efficacy strength in excess of this threshold should
have a linear relationship with success of the
behavioral attempts.
Generality of self-efficacy measurement
Bandura (1977b) has specified a third relevant
measurement dimension of self-efficacy: generality.
Generality of self-efficacy refers to the degree to
which efficacy beliefs are positively related, either
' within a behavioral domain, across behavioral
domains or across time. Generality is evaluated by
measuring efficacy beliefs over the dimensions of
concern. For example, to assess the within-domain
generality of self-efficacy to negotiate condom use
(i.e. interpersonal generality), condom negotiation
efficacy is measured with reference to the main
sexual partner and with reference to other sexual
partners (e.g. casual partners, ‘one-night stands ).
7 Between-domain generality is concerned with die
relationship of efficacy beliefs across related domains
of behavior, c.g. perceived efficacy to control one’s
caloric intake and perceived efficacy to increase one s
level of moderate physical activity. Time is the third 3

41

i ’I!

!

1

i

ii

n

1
fl

i

E.Maibach and D.A.Murphy

■ Under the CAN DO column, check M the

For the items you check under CAN DO i
indicate in the CONFIDENCE
Rate your degree of confidence by recording
column how confident
'3 a number from 10 to *00 using the scale below.
you are that you can do them.
10
20
30
40
a little
50
60
70
80
90
certain
moderately
100
certain
highly
Remember, rate what
cenain
you expect you could do
and your confidence if you were asked ,o perform .he
tasks
NOW.
HOW LONG would you
be able to KEEP yrxrr hand in .he ice wa.er if you were asked .o do
in the ice
so right now?
CAN DO CONFIDENCE

0 minute and 15 seconds
0 minute and 30 seconds
0 minute and 45 seconds
1 minute and 00 seconds
F*g- 1. Dual judgment approach to

measuring self-efficacy level
and s.rengd. (adapted from Bandura « at |987)
How confident do ’
^e^dS--ng ae.w,es? &e your confidence wi, any num.r
between 0 and 100*
scale shown below.)
0
10
20
30
40
1 can’t
50
60
70
80
90
do it
Moderately
100
certain I
Completely
can do it
certain I
can do it
Confidence Rating
Example: t can put on a condom so i. won', slip or break

CO

53

I - I can buy condoms or
find ways to get Orem a. no cos,.
or find
2. I can t
’
always
keep a condom with
me when I go out so
that I will have
.e one when I need it.

I

3. I can convince
my next new partner that wc should use
a condom.
even if (he/she) doesn’t want to.

i

i

4. I can put a condom on
(myself/my partner) and enjoy
the experience.

i

F>g- 2. Single judgment approach to

measuring self-efficacy level and

relevant dimension of self-efficaey generality
Efficacy beliefs for difficult behav.ors
J aS
motang cessation, we.ght loss and sexual absXencT

Z d“h
strain (and

-52 that
repeatedl* t0 "Nations that

strength (adapted from Maibach

and Flora, 1993).

likely to foster persistent efforts
and mastery
performances.

Creating self-efficacy items
Specificity requirements

■mreediate and more distal time ft^sXemore
42

Efficacy items should include three factors- the
behavior (or class of behavior), the level of situt

9

I
i
Self-efficacy in health promotion research and practice
_______________ Table II. Condom use elicitation interview

wU! be asking you about some of your experiences with safe and unsafe sex For cxamnle T will a v
Z
-he sexual encounters, what happened during the experiences and whaf h
< c.
P! ’ 1
k y<XJ about wha( led up to
dungs during the cou^of this intLie^T™ "
W'
o^y abouf
tndenund you may stop the interview al any time. Do you have any queXons?

OnablC W,th ttus

-------------

a"d tha’ you

<ave you ever had unprotected sex-that is, intercourse without a condonP [If ycs| I
ud .mercourse without a condom. Take a moment and try to recall as many details aswant you to think back to the last time you
possible. [Pause] Try to remember
vherc it happened the ttmc of day. how you were feeling about yourself, and how
you
were feeling about the person you were
PkUSC
yOU tCH mC ab°Ut lhc cxPcrience? [Probes to be used
as necessary.)
When did this happen?
Where did this take place9
How were you feeling prior to the sexual encounter?
How did you feel afterwards?
How long had you known this person before having sex with them on this occasion?
Had you ever had sex with (him/her) before?
What were your feelings for this person?
Did
know the HIV status of this person’ (How did you know? Was it discussed’)
Wh<
dea was it to have sex?
7
Did you discuss using condoms at any time before or during the encounter9
Did you use any drugs or alcohol before having sex?
Can you remember any other thoughts or feelings you had about the person or the encounter that
we haven’t yet talked

)nal demand and the time frame. The first task in
vising efficacy items is to conduct a conceptual
alysis of the domain of functioning to determine
: competencies involved and the barriers and
allenges one will have to manage. These barriers
d challenges may be internal or external to the
■iividual. Many areas of functioning require
ecution of multiple skills. Self-efficacy ratings are
nerally more diagnostic, and therefore more
:ful, when efficacy beliefs are measured for each
■the competencies involved. For example, if weight
Auction is achieved by diet and exercise, then
ceived efficacy in each of these domains should
measi
The diagnostic value of efficacy ratings
) depeiios on the specificity of situational demands
challenges people face during execution of the
lavior. Perceptions of efficacy for maintaining a
-calorie diet may decrease when dining with
nds in a restaurant or when only fasts foods are
liable. Similarly, situations internal to the
vidual can challenge perceptions of efficacy. For
mple, self-efficacy to negotiate safer sex may
rease under conditions of depression, loneliness
intoxication.
o the extent that the nature of the challenges
;r, self-efficacy scales developed and validated
i one population may not be applicable to other

populations. For example, a scale developed to assess
women’s HIV prevention self-efficacy may not be
relevant for men. First, the class of self-protective
behaviors are likely to differ for men and women.
The relevant behaviors for women may include the
ability to say no to high-risk sex and to talk partners
into using a condom, whereas the relevant behaviors
for men may include getting a supply of condoms,
and using them properly and consistently. Second,
the high-risk sexual situations may differ across
gender. Women may find themselves coerced to
engage in high-risk behaviors and therefore need
assertive communication skills to manage the
interpersonal coercion, whereas men may find that
drinking and drug use impairs their capability to use
condoms consistently.

CN
CD

Determining behavioral and situational
specificity
Determination of the conditions that make perfor
mance of requisite behaviors difficult requires
formative data collection (such as elicitation
procedures and focus group interviews) with
members of the population of interest. Formative
research also allows an investigator to determine
performance alternatives or adaptive behaviors that
enable people to exercise control over the problem

'4

43
‘a

I
E.Maibach and D.A.Murphy

situation. Table II presents an example of formative
interview questions used to identify internal and
external conditions that constrain (and facilitate) the
use of condoms during potentially risky sexual
encounters. A longer discussion of the methodology
required to conduct appropriate elicitation interviews
or focus groups goes beyond the scope of this article,
but has been addressed thoroughly elsewhere (e.g.
Fishbein and Ajzen, 1975; Basch, 1987; Kruger
1988).
6 ’

Assessing the components of self-efficacy to
engage in health behaviors

Once relevant behaviors and internal and external
barriers or challenges have been identified through
formative interviews conducted with the target
population, items can be developed to assess the three
components of self-efficacy: level, strength and
generality. The strength of self-efficacy for various
health behaviors is well measured by the self-efficacy
strength scale described above (see Figures 1 and 2).
Standard measures of self-efficacy strength (i.e.
0-10 and 0- 100 semantical ly-anchored scales) have
been widely used in health promotion research.
Although 0-10 and 0-100 semantically-anchored
scales are recommended, five-point fully seman
tically anchored scales (e.g. “1 = not at all sure”,
2 = slightly sure”, “3 = moderately sure”, ‘‘4 =
very sure”, ‘‘5 = completely sure”) may also be
used when administering scales to individuals with
lower literacy skills (including children) or when the
formal of administration (e.g. certain telephone
surveys) may not support a 10 or 100 point response
continuum. The benefit of using a five point scale
to assess strength of self-efficacy includes ease of
administration, especially in community settings, but
one potential cost is that response variance may be
unnecessarily restricted for individuals capable of
using 0-10 or 0-100 point scales. Restriction of
response variance will undermine the predictive
power of the measurement. Our recommendation,
therefore, is to pre-test both types of scales for
situations in which longer response scales may be
inappropriate.
Assessing the level component of self-efficacy
44

poses a special challenge for health promotion
researchers and practitioners. The level component
of self-efficacy is established by assessing selfefficacy for increasingly difficult behavioral
enactments and/or under conditions of increasingly
severe impediments to the performance (Bandura,
1977b). In other words, to establish the level
component of self-efficacy, assessment items should
be graded for difficulty. These ‘gradations’ can be
applied to either the complexity of behavior, or to
the level of challenge.
The challenge for health promotion researchers is
to identify appropriate gradation of task demands so
as to properly determine level of self-efficacy.
Bandura’s early research establishing the importance
of measuring level of self-efficacy was generally
conducted on domains of behavior for which
demands could be graded hierarchically (i.e. level
of phobic traits). For many health behaviors, there
is no natural gradation of difficulty. What may be
a strong temptation for one dieter may be weak for
another. One methodological strategy frequently used
in health promotion research to compensate for nonhierarchical behavioral domains is to sample efficacy
judgments across a variety of difficult situations.
Although conceptually sound, the approach has
practical limitations in that extensive sampling will
lead to unacceptably long assessment instruments.
Formative interviews may help determine which
difficult situations to sample for a given target
population, thereby minimizing the response burden.
Another approach to establishing behavioral
gradation for self-efficacy assessment is under
development by the authors. The approach is based
on elicitation interviews that identify challenges to
performance of the health promoting behavior (see
Table II). Relevant behavioral scenarios are
generated from the analysis of elicitation interviews.
These behavioral scenarios may be written to reflect
either gradation in complexity of the behaviors, or
gradation in the situational impediments to perfor
mance of the behavior (Murphy etal., 1994).
Efficacy judgments are then assessed in the context
of each behavioral scenario. The self-efficacy items
used with each behavioral scenario may themselves
be graded by complexity of the behavior or by the

Self-efficacy in health promotion research and practice
situational barriers. In this fashion, graded selfefficacy items are assessed for each of the graded
behavioral scenarios. An example of this approach
is presented in Figure 3.
The example in Figure 3 describes a situation in
which individuals imagine that they have been asked
by someone they find very attractive to go home with
them for the night. Gradation of difficulty is
established with these items in two ways. Each
behavioral scenario is followed by three graded selfefficacy strength questions that assess increasingly
difficult behaviors (as established in elicitation
intt
ws with the population under study). The
behavioral scenarios themselves are graded to assess
self-efficacy in increasingly difficult performance
situations (also as established in the elicitation
interviews). Admittedly, the distinction between the
behavior and the performance situation in this
example is less than perfect in that the more difficult
behaviors will tend to elicit more interpersonal
resistance, and will therefore occur in more difficult
performance situations.
Although utilizing this graded approach with
increasingly difficult performance situations will
likely result in longer questionnaires and lengthen
the time of administration, it will not necessarily
increase response burden. We have found that
respondents often enjoy this question format. The
specificity and the relevance of the vignettes
maintains their attention, and the story-like format
can be a break from typical, one-line items. The
iter
an be self- or interviewer-administered, in
either individual or group administrations. When
interviewer administered, the vignettes can be
displayed on respondent hand cards, or in the case
of group administration, they can be projected on
an overhead screen at the front of the room and read
aloud by the examiner.
The final component of self-efficacy assessment
generality—has not received adequate attention in
health promotion research, although assessment of
generality is quite straight forward. For example,
Maibach and-colleagues (Maibach etal., 1991)
assessed the generality of exercise self-efficacy across
ime by determining participant’s current confidence
o maintain a regular exercise regimen (at least three

times per week) over the course of progressively
longer periods of time (i.e. 1 week, 1 month, 1 year).
To assess generality of self-efficacy across health
behaviors. Hofstetter et al. (1990) measured
respondent’s self-efficacy to regulate their eating
behavior, exercise and medical care behaviors. As
predicted, the correlation in efficacy between these
three health behaviors was quite low, suggesting a
low level of generality.
Returning to the example presented in Figure 3,
this instrument could be altered to include
assessments of all three types of generality. Withindomain generality of HIV prevention self-efficacy
could be assessed by systematically varying the types
of relationships specified in the behavioral scenarios
(e.g. new sex partners, current sex partners). Given
the link between alcohol consumption and enactment
of HIV risk behaviors, a relevant form of betweendomain generality could be assessed by developing
scenarios that reflect situations in which members
of the population are likely to drink alcohol to excess.
The corresponding self-efficacy items would assess
confidence in ability to control one’s drinking in each
situation and/or to avoid the situation altogether.
Temporal generality could be assessed by systema
tically varying the time frame presented in each set
of questions (e.g. today, next weekend, next
summer, etc.). As can be seen from these examples,
assessment of self-efficacy generality does not pose
any particular methodological problems in health
promotion research, although it can add substantially
to the length and time of administration of the
instrument.
An additional consideration in developing selfefficacy scales is to ensure that the performances and
challenges represented in the items are sufficiently
difficult so as to avoid ceiling effects. For example,
adolescent’s perceived efficacy to “bring up the issue
of using a condom’’ may exhibit a ceiling effect,
whereas a ceiling effect is less likely with the more
challenging task of “bring(ing) up the issue of using
a condom before we start making out or undress’’.
Ceiling effects should not be a problem when
formative research is used to identify the conditions
that make performance of requisite behaviors
difficult.

I

45

F

E.Maibach and D.A.Murphy

bu' some

cCg"C«ch

given after each question.

1 -:~

-i—ionmo^ tftffcu^or^'

wi"

rcPcated two more times
you could do certain thi
questions that follow the
you arc Mng ritthr
now bv recordin
WCrC lO find1 yourself in that
recording a number
y recording
from 0 .
----- - by
(o 10 on the scale

Scene I. YOu 1have just finished a I..
walking aroundJ onc ®f your favorite areas and Ulkl^to
YoX'
for r ' "
only one drink, you f
f<xl it affecting
one
drink
/ W
-'C You ------ yourself
you a httle bn. Someone that vou’vc mctoTc^'^ ‘O Unwind
- r
attracted to. has been fliaing
' J with you. This
ElC".!h0U8h yOU havc bad
makes .tetear^^^
^-that
once —
or twice
bcfoi
o,'- :.~t you arc very
Question 1. How confident
) wants to have
arc you that
you. You are interested.
0
y°u could bring up .he issue of condoms in a
1
2
3
Not at all
5
6
7 conversation in.th.s silualion,
confident
8
9
Moderately
10
confident
Question 2. How confident
Extremely
are you that you could convince this
(hc/she) doesn
’t want to?
confident
-•'t
Person that the
0
I
two of you should use a
2
3
condom,
even
if
Not at all
4
5
6
7
confident
8
Moderatclv
9
10
confident
Question 3. How confident are you (hat
Extremely
0
you would leave this situation
confident
'
2
3
if (hc/she) refused
Not at all
4
to use a condom?
6
-j
confident
8
Moderately
9
10
confident
Extremely
hectic week.
confident
and you want to fforget your problems. You're out
you. and makes it clear thaUheZre?' dnnl“' You f«l
around again
„
.
Wa"‘5 <°
sex with you~ yoThat same person haswalking
been ftinmg
. - .
arc interested.
Question 1. how confidcn|
? with
you that you could bring up the ir—
issue of condoms in
3
4
Not at all
a conversation in this situation9
5
6
7
confident
8
Moderatclv
9
10
confident
Question 2. How
Extremcl
confident are you that
(he/she) doesn’t
confident
you could convince this person that the
want to?
0
1
two of you should use a
2
condom, even if
3
Not at all
4
5
6
7
confident
8
Moderately
9
10
confident
Question 3. How confident
Extremely
are you that
0
confident
yousvould 'ettve this situation if (he/shc) refused
1
2
3
Not at all
to
use
a
condom?
■’
6
7
confident
8
Moderately
9
10
confident
Extremely
around. Thi!Tr^e'y^" !
Wcek- an<i you want to f
confident
-kes it clear that (he/she) -anTtoX^^
d^nk'X^ "
_
scenes you’re outt walking
are interested.
M,"C person has been flirting
J with you.
>
Question I How confident
and
-you that you
gu
0
1
2
Not at all
5
6
7 3 COnvcrsab°n in this situation9
confident
8
9
Moderately
10
confident
Question 2. How
Extremely
confident
(he/she) doesn’t
arc you that you could
confident
want to?
0
two of you should use a
2
3
condom,
even
if
Not at all
5
6
confident
8
Moderately
9
10
confident
Extremely
confident

^XX^^d' 'sbecnah^^-

46

Self-efficacy in health promotion research and practice
Question 3. How confident are you that you would leave this situation if (he/she) refused
to use a condom?
0
1
2
3
4
5
6
7
8
9
Not at all
Moderately
confident
confident

10

Extremely
confident

Fig. 3. Example of graded self-efficacy questions (adapted from Murphy et al., 1994).

Developing appropriate instructions to
respondents

As with any assessment, self-efficacy items are
preceded by instructions on how they should be
completed. There are a number of issues to be
coi
:red when developing instructions to
respondents. Bandura has consistently emphasized
that self-efficacy items should assess people’s
judgments about their operative capabilities ar ofnow
rather than potential or hypothetical capabilities at
some unspecified time in the future. Instructions
therefore must encourage respondents to rate what
they believe they could actually do given current
conditions in their lives.2 (Figures 1 and 3 provide
examples of such instructions.)
A related consideration is that instructions to
respondents must encourage frank judgments.
Instructions or other conditions of test administra
tion that encourage socially desirable responses will
reduce the predictive value of efficacy assessments
(Telch et al., 1982). Instructions may require an
explicit reminder that the only ‘correct’ responses
ire the responses that accurately reflect the
participants’ confidence in their capability as of this
ime
Provision of a practice or example assessment item
>efore test administration is a useful way to
amiliarize respondents with novel question formats.
Kn example is often used in self-efficacy assessment,
ince most people are unaccustomed to answering
uestions about their degree of confidence in
apability to perform various behaviors (see
igure 2). The initial reference point provided in the
xample, however, can have an anchoring effect on
ibsequent efficacy judgments such that high initial
Terence points will lead to higher subsequent
Tcacy judgments (Cervone and Peake, 1986; Peake
id Cervone, 1989). When a scored example is used,
e score should be near the middle of the response
nge to minimize the impact of the anchoring effect.

Anchoring effects can influence efficacy judgments
even in absence of a scored example. When efficacy
items are hierarchically structured, ordering the items
from the most to the least difficult produces higher
efficacy ratings than does the reverse ordering or
random ordering (Berry et al., 1989). Therefore,
efficacy questions should either begin with the least
difficult tasks or should be listed in random order.
When conducting extensive efficacy assessments,
it may be helpful to reiterate elements of the instruc
tions as well as the response scale to ensure that
respondents are considering the same type of
information throughout. On paper and pencil
instruments, it is traditional for the response scale
to be repeated at the top of every page. Similarly
restating key aspects of the instructions at the top of
each page may help to reduce error variance.
Equivalent procedures should be employed when
verbally assessing a long list of efficacy items.

Conclusions
This article has briefly reviewed the construct of
self-efficacy, and focused on different aspects of its
measurement. Strecher et al. (1986) noted that while
most health promotion studies conceptualized selfefficacy correctly, their operational measures were
heterogeneous. Operational heterogeneity is not
problematic as long as the diverse operationalizations
are consistent with proper conceptualization of the
construct. However, we concur with Strecher et al.
in concern that the diverse operationalizations of selfefficacy in the health promotion literature actually
may not all represent the self-efficacy construct. In
this article we have discussed both conceptualization
and operationalization in hopes of encouraging opera
tional advances in the self-efficacy construct.
Returning to the aspects of self-efficacy—level,
strength and generality—it is clear that not all of these
aspects are consistently measured in health promotion

47

MD

E.Maibach and D.A.Murphy

research. Many of the studies cited in this article
assessed only the strength aspect of self-efficacy
Although true that it is not always necessaty to
measure all three aspects of self-efficacy 'and that the
purpose of the research will determine which aspects
are required, it seems clear that in many cases health
promotton researchers are not measuring aspects of
self efficacy that may contribute to a fuller under
standing of the dynamics of health behavior.
Ixvel of self-efficacy is die aspect of measurement
Wh°
reqUlrCd
health Promotion research
While the distinction between level and strength of
self-efficacy is conceptually meaningful, level and
strength measures usually correlate highly (r = 0 80
or so), ailowmg the level measure to either be
dispensed with or combined in a composite score
with strength measures for most research purposes
(I^e and Bobko, 1994). The only research that

bss of DrS
SPeC,fiC,ty °f d0ma!ns “ the
oss of p ed.ct.ve power. In-depth task analysis and
the appheafon of elicitation research should
wever help to limit the number of domains
reqmred for a thorough assessment by identifying the
most important tasks and challenges
to ^r“iVedHSe’f'effiCaCy haS becn ;hown empirically
o be an mfluential mechanism in health behavior
change m sp.te of less than optimal measurement
More comprehensive and theoretically rigorous

measures of self-efficacy beliefs should provide an
ewn better p.cture of the role of perceived self-

icacy in modification and. maintainance of he- ’'h
behaviors. Moreover, health promotion research will
benefit to the extent that methodological advances
are made m the assessment of perceived self-efficacy
o engage m health promoting practices. What is
important for future progress in the field of selfefficacy assessment, however, is the consistent
ppheauon of dictation research to identify
appropriate competencies and challenges, and to cast
the items in standardized and validated formats.

thTh'ia
meaSUreS “ reSCarCh ,o d«e™ine
threshold effects in the efficacy-behavior relation
ship (e.g. determination of the minimum level of
self-efficacy required to attempt a task).
Strength and generality of self-efficacy are the
aspects of selfefficacy measurement that merit
Acknowledgements
ased attention in health promotion research. As
noted earlier, most health promotion studies measure
only the strength aspect of selfefficacy. Moreover
■t is our observation that in the interest of brevity'
health promotion researchers often try to measure
too much with too little. Thorough assessment of selfd aft of (h.s paper. D.A.M. was at the Department
efficacy strength and generality in health promotion
Of
Psychiatry and Mental Health Sciences, Medical
research may reqmre more extensive measurement
College
of Wisconsin
man is typically conducted.
at the time of writing this
article.
This
article was
One of the mam points that we have attempted to
supported with funding from
the NIMH Multi-site IHIV Prevention Trial (NIMH
make m this review is that there is no-and can be
Grant
U10 MH49062• to E.M. and U10 MH49055
no single all-purpose approach measure of selfto
Jeffrey
Kelly).
efficacy. Self-efficacy scales must be tailored to
specific domains of functioning. There are no
standard sets of domain specific self-efficacy items
Notes
applicable to all people in all situations. Efficacy
I- Lee and Bobko (1994) compared the predictive vaiue of self
judgments are a function of both the specific

TOm

ShoiX^

e aviors and situational contexts in which they
Como
WlJ‘ Vaiy fr°m P°Pulation "> Population
Comprehensive assessments require specificity of

ST/
”™'" The
“costs of sacrificing gradam the domains.
even when assessing the generality of self-efficacy over ti^

48

t

■

The Factors That Influence The Disease Prevention
And Health Promotion

R. K. Bansal

Essay For The Unit on Introduction to Public Health

Faculty of Health Sciences
University of Limburg
Maastricht, The Netherlands

Problem Statement : The factors that affect the disease pre
vention and health promotion.
Sub-problems :
1. ) What is the latest trend and importance of health
promotion concept and why this dilemma?
2. ) What are the determinants of health in a community and
what do people think of their health.
3. ) How is the public health analysis/ diagnosis of a
community done.
4. ) How is politics and community involvement related to
health promotion and how can they be elicited.
5. ) What is the importance of the above points in the
present context of cardio-vascular diseases.
The discussion between Aart and Patrica, as I visualise,brings
out nicely the fundamental conflict in the type of approach
which should be adopted for disease prevention and health
promotion and thereby illustrates their understanding of the
term 'Health Promotion'.
Indeed Aart represents one of the classical and age-old
proponents of health promotion who visualise it in terms of
disease prevention or life-style related reduction of the risk
factors of chronic diseases (Abelin, 1991, p. 557-589). This
appears to be consistent with Anderson's (1984) views that
'disease prevention and health promotion are frequently used
synonymously as umbrella terms for activities which are car
ried out by health services, but which are not cure, care or
rehabilitation'. In
Morrell's opinion (1991, p. 590-603)
'such proponents are of danger of becoming obsessed with
They
diets,
exercise and proscribing hazardous persuits.
become concerned with healthy checks and surveys and an absurd
introversion concerning healthy living which may prolong life
but may make it utterly miserable until they terminate it by
euthanasia or suicide'. Such proponents concentrate on an
individualistic approach. However such programmes meet with a
number of hurdles, and it has been observed that individuals
are unlikely to change their behaviour or life-style if they
are not supported by the networks to which they belong (Abelin, 1991, p.557-589). Besides there are other problems which I
would reflect upon later.
Patrica represents the other class of proponents who reali
se that disease prevention and health promotion are not dis
crete/ ad-hoc activities in themselves, which could be planned
and implemented by them without the active involvement of the
community, nor without considering the total milieu thereof.
Their concept goes beyond that what relates to their goals, as
reaching for a more positive state of health and not merely
for a reduction of risks and illness. They believe that health
promotion has increasingly gone beyound the transmission of
cognitive contents to individuals, such as is characteristic
of traditional health education, to include interventions at
the levels of social- support networks, organisations, the
political arena and the economy (Abelin, 1991, p.557-589).
Research in social epidemiology indicates that beyond mecha-

nisms involving known risk factors, social support is not only
an element of a better quality of life, but that it is also
directly associated with longer life expectancy (Berkman and
Breslow, 1983).
Both the groups are concerned with altering patterns of
human behaviour detrimental to health, as revealed by various
earlier studies, as smoking, elevated blood pressure, elevated
serum cholesterol etc. (PPRG, 1978). The difference is in
their beliefs and approach, an understanding of which is cent
ral to any health promotional venture and therefore I intend
to bring out some of the complexities inherent in the issue.
Aart assumes that the community realises cardio-vascular
diseases as a public problem, whereas Patrica feels the need
for the communities opinion and their active involvement.
Gusfield (1981, p.1-23) had argued that problems are rarely
directly contrued as public problems generating 'true consciouness' Usually problems have histories and a time revelvance
context (Rosen, 1968) . A corollary of this could be that a
disease or it's association with risk factors may not be
recognised as a public problem needing immediate resolution.
Therefore prior to any health promotional venture it may be
prudent to assess the opinions and needs of the community and
(Bennett, 1979),
go for a preliminary community diagnosis (Bennett,
though without strictly adhering to the classical 5 steps
(Gideon, 1977). The citral idea is to get a feel of the commu
nity. Our literature review itself may provide us with invalu
able informations.
The step of community diagnosis provides for a sound epide
miological grounding of a health promotional venture. It may
reveal that there are no sufficient merits of the proposed
intervention (Kok and Green, 1990) or else it may help us to
assess the magnitude of the problem and the views of the
community about it. In the absence of a percieved community
need for an actually existiong problem a demand for interven
tion needs would have to be generated by developing a public
consciouness. Alternatively associating ourselves in enabling
the community solve their public needs may help us win their
respect and make them more receptive to us. Both of the afore
said potentially provide us a good entry point into the commu
nity.
Another point which clearification before proceeding further is that the high-risk factors need to be viewed as a
component of the determinants of health in totality. By and
large health educators tend to adopt an individual behavioural
change approach, 'victim-blaming' , wherein they pathologise
and label certain types of social behaviour and conduct as
unhealthy 'lifestylism' (Rodmell & Watt, 1986, p.1-15), but
they fail to realise that this could lead to a sense of moral
failure and emotional inadequacy.
According to Naidoo (1986), three major criticisms can be
levelled against individualistic health education: first, it
denies that health is a social product; second, it assumes
that free choice exists; third, it is not effective within
it's own terms of reference. On the other hand it is also
important that individuals and groups can make some choices.
The need is to come to a balance of these two in broader terms
while considering the total environment (Rodmell & Watt, 1986,
p.1-15). It must be realised that an individual or a group may

not be able to exert absolute control over the environment, as
is for nutrition (Charles & Kerr, 1986) . Their is a need to
make healthier choices easier choices (Dennis et al., 1982).
Also by and large the individualistic approach tends to con
centrate on the small segment of high risk cases and neglects
the outnumbering people with moderate risk who would factually
account for any significant changes in the morbidity profiles.
The advantages and sucess story of an health promotion
programme doing justice to many of the aforesaid issues could
be the North Karelia Project, 1972-87 (Me Alister et al.,
1991). The project started on a solid footing as it was initi
ated subsequent to a demonstrated need. The project staff
could sucess-fully deal with the matters pertaining to health
analysis and health issues, determinants of health and in
volvement of politics and community in their promotional
efforts.
The project was able to tee attract intense and frequent
media coverage and inter-personal communications with various
social structures.lt used strong positive emotional approach
to persuation, to associate the goals of the project with the
pride and provincial identity of the population. They adopted
a mix of various strategies at the community and the individu
al level in order to re-inforce their strategies, some of
which were:
1) Actual training in new cooking and food preparation skills
in changing family diets alongwith social programmes both for
the participants and the non-participants.
2) Actual modelling for skills training targetting at smokers.
3) Persuation and social reinforcements directed at healthier
food, smoking etc.
4) Incentives and penalties, with emphasis to positive ones.
5) Facilitating environmental changes and social policies.
6) Reorganisation and consolidation of preventive services.
The project could sucessfully demonstrate a change in the
societal life-styles and the rate of iscgaemic heart disease
mortality.
Conclusion
Since the publication of the Medical Nemesis (Illich, 1975) , 7
it is being realised that by and large health promotion/
health education has adopted an unjustified reductionist and
medicalised stance (De Leeuw, 1989). This essay argues for a
systematic and holistic approach to health promotion in order
to tackle the public problems of the community, including
those related to health, by involving, empowering and enabling
them in actuality. This is vitalif we are to translate into
actuality our rhetoric of 'Health for All'.

CotA H
7^

DEBORAH JAFFE SANDROFF, MS
SUZANNE BRADFORD, RN, BS
VERONICA F. GILLIGAN, MS

MEETING THE HEALTH PROMOTION
CHALLENGE THROUGH A MODEL
OF SHARED RESPONSIBILITY

From Total Life Concept
AT&T
Chicago, IL (DJS); Pleasanton,
CA (SB); and Basking Ridge,
NJ (VFG)

Reprint requests to:
Deborah Sandroff, MS
Regional Manager
Total Life Concept
AT&T
227 Monroe, Sth Floor
Chicago, IL 60606

With a majority of American companies
offering some form of worksite health promo
tion program, the trend toward prevention of
illness rather than treatment of disease continues
to grow.24 These companies see health promo
tion efforts as logical cost containment strategies
because they attack health problems at their
source.I3,18-27’32 The proliferation of these pro
grams has provided a wealth of information on
the relative merits of a variety of health promo
tion models. This experience base offers worksite
health professionals the opportunity to enhance
their programs with exciting and innovative
strategies for the future.
The traditional medical model in most
worksite programs focuses on the treatment
needs of the individual. It emphasizes self
responsibility and directs the client toward
developing skills to achieve success in personal
health. However, this approach, when used
exclusively, tends to place blame on the individ
ual when change is not forthcoming and to
neglect other factors that influence individual
health behaviors.1-14-25-27 As a result, long-term
success may be limited.
AT&T’s Total Life Concept (TLC) pro
gram has incorporated a multidimensional
strategy for health promotion that attempts to
avoid the pitfalls of a unifocal individual
approach. Combining individual, organiza
tional and environmental health promotion
efforts, TLC has adopted an “ecological”

OCCUPATIONAL MEDICINE: State of the Art ReviewsVol. 5, No. 4, October-December 1990. Philadelphia, Hanley & Belfus, Inc.

677

678

SANDROFF, BRADFORD, GILLIGAN

model, which is described in this chapter. The central philosophy that unifies
these three dimensions is a “shared responsibility” for health. Just as individual
citizens, local community practices, and government regulations must act in
concert to prevent the erosion of our ecological balance, so too must employees
and the organizations for which they work share responsibility for their mutual
well-being. The reality is that there are no blank checks for the future in terms
of natural resources, personal health, corporate survival, jor health care
services. Effective worksite health promotion recognizes the need to facilitate
partnerships for achieving the mutual goals of health and high performance.3.8-’2,2i,25,27

EXPERIENTIAL ECOSYSTEM
The development of an individual’s health behaviors is influenced by a
myriad of personal experiences. Figure 1 illustrates the kinetic force that these
factors exert within an individuafs “experiential ecosystem.” This complex
interplay of variables largely beyond a person’s control molds health values an
beliefs and the corresponding health behaviors that an individual practices. An>
program aimed at modifying individual health behaviors must recognize these
dynamics and target strategies to the system.2’11’22
Successful corporate health promotion programs focus their efforts on
variables on which they can exert influence. These will be referred to as internal
experiences since they occur within the organization. Typically these include
occupational health exposures, psychosocial work experiences, and employee
benefits. While the other experiences within the ecosystem are largely beyond the
purview of the health promotion program or the corporation, they too must be
Family Values
& Practices

Socioeconomic
Status

\
Education

Social Norms

Environmental
Exposures

Individual
Health
Behaviors

Community Health
Care Resources

Occupational Health
Exposures

Psycho-Social Work
Experiences

Media

Employee Benefits

Religion

FIGURE 1.

Public Health Policies
and Legislation

Experiential ecosystem.

A Model of Shared Responsibility

679

considered during the program planning process. These will be referred to as
external experiences—factors outside the workplace.
It is critical that program planners understand that the relative effects of
internal versus external experiences differ among individuals. For some people,
worksite variables can serve as very powerful factors for influencing health
behavior changes. For others, these internal variables are not very influential and
the external experiences are stronger predictors of health behaviors. As health
promotion professionals gather more data from implementing programs in a
variety of work settings, it will be important to determine to what extent
socioeconomic status predicts how much a person is influenced by internal versus
external experiences. For instance, are blue-collar workers influenced more by
family values and practices and the norms of their social group than by
psychosocial work experiences? If so, health promotion planners must develop
campaigns for influencing family practices concurrently with individual behaviors.
DIMENSIONS OF HEALTH PROMOTION
Figure 2 presents a conceptual framework for worksite health promotion
that incorporates three key dimensions: individual, organizational, and environ
mental health promotion. It ties together elements from the experiential
ecosystem in a configuration that highlights those areas upon which the program
can have the greatest impact. The AT&T health promotion process is based on
this framework.10
The individual health promotion dimension represents health behaviors and
related variables from the person’s external experiential ecosystem. In contrast,
the organizational and environmental dimensions encompass internal experiences
INDIVIDUAL

ORGANIZATIONAL

/ HEALTH STATUS
VALUES
BELIEFS
PERSONAL STYLE
BEHAVIORS
FAMILY PRACTICES X

/
'

WORK STYLE
FITNESS CENTERS
CLEANLINESS
SMOKING POLICY
SAFETY BREAKS
HEALTH
y
\ RESOURCE /
\ CENTERS/

CULTURAL NORMS
POLICES &
PROCEDURES
VALUES
\ BELIEFS

PHYSICAL WORK ENVIRONMENT
- ERGONOMICS
- SAFETY RISKS
. - CAFETERIA & VENDING >

ENVIRONMENTAL

FIGURE 2.

Dimensions of health promotion.

680

SANDROFF, BRADFORD, GILLIGAN

at the worksite that affect personal health behaviors. Psychosocial work
experiences and employee benefits as illustrated in Figure 1 are examples of
variables in the organizational dimension. Occupational health exposures as
illustrated in Figure 1 are incorporated in the environmental dimension.
The three dimensions must be viewed as closely interrelated. A crisis in one
area quickly impacts and sometimes overshadows the others.15 For instance, a
person who, on the individual dimension, has a family crisis such as the death of
a loved one or learns of a serious health condition comes to the workplace with
feelings and concerns that can influence the other two dimensions. The organiza
tion can be affected if the person’s interactions become strained as a result of
personal preoccupations and stress. Likewise, safety risks can be increased if the
person is distracted. Parallel repercussions in the individual and environmental
dimensions result when major organizational changes occur such as downsizing,
reorganization, and policy revision. In turn, catastrophic accidents in the
workplace affect both the organizational climate and individual behaviors. The
tragic Union Carbide accident in Bhopal, India had a grave impact on both
personal lives and worksite norms. Thus, these dimensions coexist in a dynamic
equilibrium. Program planners must understand the forces within each dimension
that create this balance.
In the area where the circles intersect in Figure 2 are listed examples of how
the three dimensions can come together as part of the health promotion process.
“Work style” refers to the behaviors that people adopt in work settings relative to
communicating and interacting with others, pacing their work, and structuring
their tasks. Often, this can differ significantly from the “Personal style,” which is
those behaviors they use in environments outside work.17 Helping individuals
and work groups to understand their work and personal styles can enhance both
individual and team effectiveness. At AT&T this is done through organizational
health initiatives, which are described later in this chapter.
Fitness centefs provide individuals a convenient means of scheduling regular
exercise into their work day. While they house an important individual health
promotion intervention, they also serve as organizational and environmental
strategies. The building of a fitness center makes a very strong statement about
the organization’s commitment to the health and well-being of its employees. On
an environmental level, fitness centers reinforce the message that “around here
we provide opportunities for employees to practice positive health behaviors.” In
locations with on-site fitness centers, it is common to see upper-level managers
exercising with subordinates. In addition, the fitness center can become a
strategic location for informal networking among departments.
Cleanliness of the workplace, smoking policies, and safety education are
examples of areas in which individual well-being and quality of work life merge.25
If these factors are ignored, no amount of effort to encourage individual behavior
change will be successful. Employees will see the inconsistency between the health
promotion message on one hand and the employer’s lack of concern for safety
and hygiene on the other.
Other examples of the overlap between individual and environmental health
concerns include videodisplay terminals (VDTs) and ergonomic issues.25-30
Companies are faced with the challenge of designing workstations that prevent
occupational health problems and educating supervisors and employees about
methods to avoid injury, fatigue, and musculoskeletal disorders. A case at one
AT&T location illustrates this. A coalition was formed consisting of ergonomic.

A Model of Shared Responsibility

681

safety, and building engineers, occupational health physicians and nurses, and
the health promotion staff. Their collective expertise was used in cooperation
with local management to develop a comprehensive and creative approach to this
problem area. Ergonomic and safety engineers worked with employees and
supervisors to evaluate the workstation design, making adjustments and recom
mendations to eliminate postural stress and ease fatigue. The occupational health
team, including the health promotion staff, worked together to develop and
implement educational interventions that teach employees how to prevent
stressors and practice exercises that will reduce health risks.
Health resource centers provide another means of reinforcing the health
promotion message within the work environment. Dedicating space for health
education literature, videos, self-administered blood pressure checks, and
computer programs communicates to employees the company’s support of
individuals’ efforts and its expectation that health be regarded as a shared
responsibility.
The relationship between individual and organizational health is a foundation
for other health promotion strategies. For example, mitigators for controlling
stress include social ties and informal networks such as neighborhoods, churches,
and volunteer organizations. By recognizing this fact, the corporation can work
to create a positive, supportive atmosphere even during periods of extreme
change.8-25 Forming partnerships to offer a variety of programs that enhance
positive and creative thinking helps establish optimal organizational health.
These partnerships can integrate the work of the health promotion staff and
managers in areas such as human resources, corporate education and training,
and public relations. Studies also indicate that programs that are most likely to
stimulate organizational change are those that stress the importance of reaching
people at all levels of decision making and that apply all levels of intervention.
Therefore, the health promotion program should target the worker, the work
unit, the corporation, and the community.22
THE TOTAL LIFE CONCEPT PROGRAM MODEL
The Total Life Concept (TLC) program, AT&T’s health promotion process,
has evolved during its 7-year existence to employ a flexible model of program
implementation and expansion. This model was developed to facilitate a consistent,
cost-effective approach to health promotion that incorporates the three dimensions
described above. Research indicated that the original design for TLC implementa
tion, primarily an individual health promotion model, was successful in achieving
some of its key objectives.9’I0’28 However, the program was impractical from an
administrative perspective. It would have taken many years to slowly expand the
program to reach all AT&T employees given the demands for staff and resources
in the original design. As a result, a new model for TLC implementation and
expansion was developed. Figure 3 illustrates the TLC process.
- Management Commitment. TLC staff initiates the program with AT&T
organizations or locations by securing management commitment from the
groups’ leaders. This step is the cornerstone of the organizational health
dimension of the process. Through meetings or presentations to key decision
makers, an overview of TLC is provided along with the staffs expectations
regarding managers’ commitment to the precess.
Top managers are asked at the outset to participate actively in examining
the factors that inhibit their employees’ personal growth and health. This is the

•>

682

SANDROFF, BRADFORD, GILLIGAN

Management
Commitment

2

3

Steering
Committee
Formation

Baseline
Data
Collection

8

9

Follow-Up

Evaluation

7

4

Strategic
Planning

Initiation

6

TLC Leadership
Committee Selection----And Training

5

Management
Programs

FIGURE 3. The Total Life Concept (TLC) process.

most important element in defining management commitment, because it reflects
an acceptance that the organization shares responsibility for the health of its
employees.
During this first step in the process managers must agree to allocate
resources to TLC based on the scope of the local strategic plan. TLC guidelines
stipulate that the TLC budget will cover costs associated with all but one step in
the process. However, program costs during follow-up (Fig. 3, Box 8) are shared
by local management and the employees themselves. In addition, managers must
commit a portion of the organization’s time to the process on an ongoing basis.
This acknowledges the importance of providing work time for organizational
health seminars. Leadership Committee training, ongoing activities of this
committee, and other opportunities for employees to participate in health
promotion interventions as part of the workday.
~ Interestingly, the time commitment is often an easy one to make and a
difficult one to keep. While TLC staff acknowledges that business priorities
always take precedence, it is sometimes frustrating when the long-term benefits
of the health promotion process are sacrificed to address short-term crises. It is
the far-sighted manager who recognizes the importance of maintaining efforts to
enhance employee well-being, especially during a crisis.7
Steering Committee Formation. Upon committing support to the initiation
of the health promotion process, management is asked to form a Steering
Committee. The function of this group is to serve as the decision-making body
that is responsible for formulating a strategic plan and allocating the resources
necessary for implementation. It also provides ongoing guidance to program
planners and the Leadership Committee. The Steering Committee may be an

A Model of Shared Responsibility

683

existing executive body whose responsibilities expand to include health promotion.
Otherwise, it is a group charged to formulate a health promotion strategy that fits
the needs and resources of the organization.
Data Collection. In order to evaluate the needs and interests of each group
embarking on the health promotion process, data related to the three dimensions
of health promotion are collected. This provides program planners with
information to customize the TLC program for the particular site.
Primary data sources are the AT&T Health Audit and focus groups. In
some cases, additional information is gathered. The AT&T Health Audit is an
organizational survey that serves as the cornerstone of the data collection
process. Developed internally at AT&T, this instrument assesses personal lifestyle
practices, characteristics of the work environment, perceived organizational
norms relative to health, sources of support, interests in making health and
lifestyle changes, and self-efficacy.26 Generally, it is administered before health
promotion initiatives are launched to gain a “snapshot” of the needs and interests
of each group. These data also serve as a baseline for later program evaluation.
Each new group that is assessed is compared to a “norm group” of all
respondents to the Health Audit during the previous 12 months. This allows each
organization to evaluate its needs relative to a broad cross-section of AT&T
workgroups from around the country. This comparison might show, for
example, that a group has a higher incidence of smoking than the national
average for AT&T employees, suggesting a strong need for interventions and
policy formation in this area. On an organizational level it might indicate that a
group has a higher level of morale than the national average, prompting
managers to examine what is being done “right” and captilize on those efforts.
The experience of the TLC staff has been that the information provided in each
Health Audit report is invaluable for program planning. It provides an empirical
basis, not just an intuitive one, for making program decisions.
A second means of obtaining information for program planning is through
focus groups. These are generally meetings, lasting about an hour, with 7 to 12
employees from the organization(s) or location being assessed. They represent a
cross-section of employees with respect to age, gender, racial/ethnic background,
occupational status, and job function. The purpose of these focus groups is to
clarify information obtained through the Health Audit and gain employee input
on questions that are difficult to ask in a survey format. Directives for the group
include: “Describe a typical workday and the types of problems, stresses and
demands that you face” and “How can your workgroup’s experiences with other
programs in the past guide plans for health promotion?” This information, in
conjunction with the Health Audit data, enables program planners to make
recommendations for tailoring the program to meet the unique needs and
interests of each particular group.
Focus groups can run the risk of deteriorating into gripe sessions where
complaints of a diverse nature about the company get dumped. While it is critical
for program planners to be aware of these issues, participants are guided to focus
on concerns and problems that relate to the viability of health promotion efforts
and have a potential for change.
With large organizations within the company (n > 5,000), further information
about the employee population can be accessed from medical claims and
disability/absence data. These incidence and prevalence data from large groups
provide greater detail for strategic planning and evaluation purposes. At other

%

684

SANDROFF, BRADFORD, GILLIGAN

times, company-wide medical claims and disability data are used with smaller
groups as reference points for program planning.
Strategic Planning. After compiling the results of the Health Audit, focus
group discussions, and any other data TLC staff and the Steering Committee
meet to formulate a strategic plan for health promotion. However, the first issue
to be addressed is whether the organization is able to proceed as planned with the
health promotion process. Sometimes sudden organizational changes make it
difficult for management to fully commit the resources initially allocated for the
program. Modifications to the original design may be necessaiy under these
circumstances.
Planning begins by addressing budget allocation, time allotment for
participation in program interventions, composition of the Leadership Committee,
management seminars, and space allocation. The Steering Committee also
defines the operating guidelines for the Leadership Committee.
Management Programs. TLC’s overriding goal is to establish an active
commitment to health as a central business strategy. Since a company’s success
is dependent upon the productivity of its workers, and productivity is directly
linked to employees’ physical and emotional well-being, health promotion is
defined as a necessity rather than a perquisite.12 The message that “good health
is good business” needs to be communicated from the company’s top leaders in
order to establish their expectation that all employees will share responsibility by
learning to live and work well.
TLC staff have developed a set of interventions for managers as a core for
organizational health promotion. These sessions range from an overview of the
program to acquaint all supervisors with TLC to more intensive seminars that
focus on the connection between health and productivity. Managers are
challenged to examine their impact on the health of their employees and establish
goals for creating healthy norms for regular business practices.
The INSIGHT Inventory17 is used to enhance participants’ understanding of
their own personality strengths as well as differences among co-workers’
communication styles. Participants are encouraged to use this insight to improve
their personal effectiveness both on and off the job. Supervisors are'also invited
to involve their work groups in team-building sessions, using the INSIGHT
Inventory to promote team effectiveness and mutual support for health behavior
change.
Management seminars also encourage the integration of health promotion
into other systems within the company. Research has shown that a contributor
to successful program institutionalization is the ability of the organization and
the health promotion program to work together.29 At AT&T the health pro
motion message is reinforced at an organizational level with TLC seminars for
high potential managers and emerging leaders being offered at regular intervals.
As the “health banner” gets waved increasingly by nonhealth professionals at
general business functions, positive health norms have a greater opportunity to
solidify.
Leadership Comnuttee Selection and Training. A Leadership Committee
is established to coordinate the delivery of the health promotion process for a
particular location or organization. It is comprised of a representative group of
employees who have been selected on the basis of criteria established by the TLC
staff. The size of these committees ranges between 8 and 12 members. Whether
committee members are appointed by local management or chosen through an

A Model of Shared Responsibility

685

interview process conducted by TLC staff, the group is comprised of individuals
who actively demonstrate positive health behaviors and thereby serve as good
role models.
An effort is made to avoid the “wellness warrior” or “fitness fanatic” since
zealots on the committee can intimidate others. At the other extreme, smokers
and persons who are very obese have difficulty serving as productive committee
members because of the tension between the committee’s mission and their
personal struggles. In general, such individuals may work better as members of
subcommittees rather than the core Leadership Committee.
Other qualities that help identify Leadership Committee members include
good interpersonal communication skills; positive relations with and credibility
among co-workers; a high level of organizational skills; experience giving group
presentations; a supervisor who is willing to acknowledge participation on the
committee as a work responsibility; creativity, self-confidence, optimism, and
other positive personal attributes.
The TLC Leadership Committee members participate in a 2!4- to 3-day
training session conducted by the TLC staff. The purpose of the training is to
clarify the committee’s responsibilities; promote teambuilding; increase members’
understanding of health promotion and the TLC process; acquaint them with the
core components of safe, effective health behavior change concepts; review other
programming options including use of community resources; and establish an
action plan for the program.
After training has taken place, the real work of the committee begins. With
the TLC staff serving as consultants, each committee functions independently
and establishes its own infrastructure. TLC’s experience has been that with good
organizational support. Leadership Committees are capable of implementing
exciting and creative programming ideas. Perhaps this is because these groups
are not bound by the constraints of traditional health promotion approaches; or
maybe their sense of ownership and belonging enrich their commitment. For all
of these reasons, the TLC staff have found Leadership Committees to be an
invaluable asset to cost-effective and successful expansion of the program.
Initiation. Initiation of TLC is planned and carried out by the Leadership
Committee with the guidance of TLC staff. It is geared to the unique needs of the
targeted group and is approved by the local Steering Committee based on
strategic planning criteria.
The TLC model predicts change to occur in a multidimensional mode.
While the initiation phase often has a strong individual health promotion focus,
organizational and environmental health promotion objectives are also addressed.
The ultimate goal of individual health promotion is that individuals will
incorporate positive health behaviors into their daily lives. Fundamental to this
process is an initial health awareness intervention. The purpose of this event is to
announce the beginning of the program, generate enthusiasm among employees,
communicate the organization’s commitment to personal well-being, and introduce
opportunities to change health practices. This intervention may be in the form of
a classroom-style orientation, but more often a health fair or another type of
upbeat, high-energy kickoff works best to launch the program. Prizes, contests,
colorful decorations, healthy refreshments, and high employee involvement all
help to make a strong statement about the nature of the program.
During this initial intervention, or at a subsequent session, employees are
given an opportunity to complete a Health Risk Appraisal. This computerized

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SANDROFF, BRADFORD, GILLIGAN

questionnaire assesses a person’s level of risk based on individual and family
health history, lifestyle behaviors, and biometric testing data. Current data are
obtained by providing on-site measurement of height, weight, blood pressure,
and cholesterol.
Feedback on individual health risk appraisal (HRA) results is given at a
follow-up wellness planning session. This component of the individual health
promotion process is considered critical. Its purpose is to explain the results of
the HRA and thereby personalize the concept of risk, examine individual health
beliefs, and stimulate participants to establish lifestyle goals. The importance of
support, skill development, knowledge, and motivation are reinforced.4-23 In
addition, the differences between controllable and noncontrollable risk factors
are discussed. This helps participants to formulate a realistic strategy for making
behavior changes.16-27
A central challenge during the wellness planning session is to communicate
the importance of personal control and self-responsibility. Participants are
helped to recognize that lifestyle behaviors are a matter of choice; for example,
individuals control what they put in their mouths, be it cigarettes, high fat foods,
or alcohol. They also make choices about engaging in regular exercise. The
difficulty for many people is that they lack confidence in their own abilities to
change behaviors successfully. This sense of personal control, or self-efficacy, is
difficult to acquire simply by learning about its importance during wellness
planning. By reviewing its significance, staff help participants to recognize the
importance of setting reahstic goals and targeting change for only one risk factor
at a time. As participants gain confidence through success in one area, their sense
of self-efficacy grows and they more readily attempt previously unsuccessful
changes.6
A common attitude among health promotion participants is, “Do it to me.”
Employees hope that someone can magically provide them with easy answers
and quick fixes to long-standing struggles. This mindset is challenged during
wellness planning. Participants are reminded that unless they are willing to invest
time and energy, as well as deal with setbacks, they will probably be disappointed
in the results.
At the conclusion of wellness planning individuals are asked to develop an
action plan that targets an attainable, reahstic goal. They are informed of
available resources both at the worksite and in the local community to assist
them with their goals.
Follow-up. As a follow-up to the initiation phase, on-site classes, programs,
and support groups are organized by the Leadership Committee on the basis of
the population’s needs and interests. In addition, self-help materials, special
campaigns, lunchtime presentations, and resource centers are provided to
stimulate positive health behavior change.
During the past 7 years TLC has been most closely identified with such
modules as stress management, hypertension control, cholesterol reduction,
general nutrition, weight management, back care, interpersonal communication,
smoking cessation, cardiovascular fitness, and aerobics. When these modules are
offered, a determination is made during strategic planning as to who will bear the
costs.
As the program has evolved, the focus of individual interventions has
expanded. AIDS awareness, wellness for women, parenting, prenatal care, issues
in eldercare and others have been added to enrich people’s opportunities to

A Model of Shared Responsibility

687

achieve optimal well-being. By responding to emerging health care and social
issues, health promotion programs evolve to serve employees’ needs.
The TLC program has placed a high value on several fundamental elements
to ensure the success of individual health promotion efforts:
• A strong emphasis is placed on the voluntary nature of the program so
that employees perceive it as free of coercion.
• Confidentiality is assured.
• Staff members have strong interpersonal skills and relate well to the
employee population.
• Program facilitators serve as positive role models for healthy lifestyle
behaviors.
• Employees perceive inherent personal benefits to participating in the
programs, independent of the corporation’s agenda.27
• Skills attainment and behavior modification methods such as self
monitoring and record keeping are targeted in addition to knowledge
acquisition.
• Individuals are encouraged to modify both their behavior and their
environment.
• Change is nurtured in the context of support from friends, family, and co
workers.
• People learn best when they are having FUN!
The program options provided during follow-up are planned to achieve the
objectives outlined during strategic planning. Therefore, classes, support groups,
and other strategies aimed at individual behavior change are only one dimension
of follow-up. In addition, organizational and environmental interventions are
provided to achieve specific goals in those areas. Ideally, these can also be
integrated with other company programs such as environmental health and
safety, quality, training, and employee assistance.
This integration requires gaining access to the many company programs that
already exist. Managers can play an important role in identifying and facilitating
these opportunities. One very practical reason for this approach is to prevent
reinvention of the wheel and instead fit health promotion components into
existing programs. This reduces costs and provides more health promotion
exposure to the work force.
An illustration is the successful integration at one company site of TLC
behavior change classes into an existing seif-improvement program, Leam-atLunch. This program offers various educational opportunities for individual
growth and development to better prepare employees for the constantly changing
information movement and management industry. TLC classes naturally fit into
this educational process, thus becoming part of the framework to enhance
employees’ skills for planning and managing their futures.
Evaluation. Evaluation of the TLC process is currently performed through
readministration of the Health Audit for 1- to two-year follow-up. In addition,
AT&T is now looking at more long-term changes in medical claims, disability
absence, health risk appraisal data, and other health risk indicators. The results
of periodic evaluations are fed back to Steering Committees for consideration in
modifying their implementation plans.
In a study assessing the initial implementation of TLC there were implications
of significant long-term health benefits as well as changes in employee morale.9’10-28

688

SANDROFF, BRADFORD, GILLIGAN

Ongoing evaluation will determine the extent to which the TLC process
continues to promote these benefits.
IMPLICATIONS
A healthy organization is critical to the balance of a worksite ecosystem. It
provides the foundation upon which all other health promotion initiatives can be
built. In the absence of healthy organizational practices, individuals find their
personal efforts to improve their health being sabotaged by the expectations and
interactions of their daily work experiences. The challenge of organizational
health promotion is to develop and implement strategies that support and
enhance worker health and productivity. The ultimate purpose of these efforts is
to solidify an understanding among all levels of employees that workplace norms
and values are health risk factors that must be addressed by all members of the
organization.7
When managers successfully grasp the organizational health concept and
health promotion values become woven into worksite norms, new trends gain
momentum. Some managers incorporate health enhancemerxt activities into their
staff meetings and conference agendas. Humor presentations, exercise breaks,
and group energizers are replacing the cigarette break at some meetings.
Reducing the risks associated with smoking is one example of the organizational
health promotion process. Teams of managers, employees, and health promotion
professionals can work together to reduce the incidence of smoking in the
workplace. At more and more locations employees are using positive strategies to
limit or ban smoking in the workplace, educate families, and participate in
community programs such as the Great American Smokeout. Employee involve
ment empowers the cultural change effort and creates a sense of community.3
Employees work together to seek solutions to issues rather than polarize the
work group.
Figure 4 is an adaptation of the health continuum developed by John
Travis, M.D.5 It shows organizational health on a spectrum between illness and
wellness as a parallel to individual health and well-being. The left end of the
continuum, where traditional health care benefits and policies typically concentrate
their efforts, represents organizations that focus on employees as commodities.
These companies’ policies, employee benefits, and cultural norms tend to “fix”
rather than prevent” conditions that lead to high mortality, morbidity, disability,
and employee turnover. The right end of the continuum represents organizations
that have implemented comprehensive health promotion and human resource
strategies as preventive measures. These healthy companies view their employees
as resources and strive to achieve high performance, job satisfaction, and
optimum health.25
Organizational policies and norms may also impact health care expenditures.
Research continues to point toward preventive measures as one of the best means
for managing the rate of increase in health care costs.1318’27 This has tremendous
significance for corporations as they battle to secure corporate profits against the
ravages of rapidly increasing health care spending.
The multidimensional approach to health promotion takes the financial
rewards of preventive measures one step further. By effecting change through
environmental and organizational health promotion strategies, companies
capitalize on support for positive, sustained health behaviors through systems
that are already part of the worksite. These include management practices,

A Model of Shared Responsibility

689

Higher Utilization of Health Care

Managed Health Care Costs

High
Mortality/
Morbidity/Disability/
Turnover

High Performance
Job Satisfaction
Optimum Health

Neutral Point

I

J L
Traditional Health Care Benefits & Policies

J
Comprehensive Health Promotion & Human
Resource Strategies

Illness

Wellness

FIGURE 4.

Organizational health continuum.

cultural norms, and employee involvement in the health promotion process. This
model enforces shared ownership for the health of the work force and the
company and is less at risk of losing program dollars due to financial constraints.
In contrast, the individual health promotion model requires a large budget and
extensive staff resources and works only when the company is doing well.
AT&T has recently introduced a comprehensive benefit package to assist
employees in balancing job and family commitments. The company and
supervisors must be committed to providing a caring, supportive environment.
These initiatives complement the goal of achieving optimal organizational health.
As the culture changes to support these objectives, AT&T’s position on the health
continuum will continue to move toward high-level wellness. TLC sees health
promotion as an appropriate vehicle to communicate these values, since the inter
action between family life and psychosocial work experiences has a significant
impact on individual and organizational well-being.19-20
TLC’s challenge for the future will be to monitor AT&T’s status on the
organizational health continuum and continue to develop innovative strategies
for stimulating healthy organizational norms. Through a variety of initiatives, to
address emerging trends, TLC hopes to translate the message that “good health
is good business” into a long-term reality for AT&T.
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Ecology in the school environment
Rainer Bachmann

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A framework for health promotion policy: A discussion document

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HEALTH PROMOTION
5 Oxford Univenlty Pmi lOSfi

Vol. I. No. J
Primed in Crem Britain

Reviews
Social inequality and healthy public policy
Ronald Labonid

341

Health promotion and health education:
Living with a dominant concept

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The role of broadcasting in health promotion in North America

353

Carol Haslam
Lifestyle, stress and work: Strategies for health promotion

HANS SAAN

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Dutch Health Education Centre, The Netherlands

Malcolm Weinstein
Approaches to holistic health promotion at the workplace

373
The recent foundation of this journal justifies
the recognition of health promotion as a new and
dominant concept in the thinking on health.
Dominant concepts act as magnetic poles to our
mental processes. They help us to determine the
main directions of our daily efforts. New con
cepts have a special attraction because they mean
many things to different people, who all share
the feeling of working on something new and
promising.
Health promotion derives part of its popu
larity from a combination of values: community
development, participation, equity and an
ecological perspective on health. This perspective
and these values reflect a general trend in society
and health promotion is its exponent in the
health field. It offers a frame of reference for
policy analysis and. development.
In the last decades health policy has developed
mainly in response to the growth of medical tech
nology and hospital care. Efforts to control and
structure these developments created administra
tive structures with little attention to a broader
health policy. Recent distrust of the output of the
medical system in a period of economic decline
resulted in a strong call for redistribution of
public funds. Criteria for this have to be derived
from
new policy framework in which health
promotion is the dominant concept.
In its development health promotion has been
strongly supported by health education. Profes
sionals in this field are working at the crossroads
of health and'education. Living between two
professional cultures, they are very much aware
of the ideological implication of their work. This
is mirrored by the introductory chapters in most
textbooks on health education.

Helmut Milz

Protocol
The East Finland Berry and Vegetable Project: A health-related structural intervention
programme
^85
Jussi Kuusipalo, Marja Mikola, Sima <1iVtoiiio and Pekka Puska

News
Development of a national health promotion survey: The Canadian experience

393

Irving Rootman

WHO acts against tobacco: A report
Jill Turner

401

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Dotnio* Printer* Limited. Br»dford on-A»on. Wiluhire

Health education by its nature has to consider
issues of personal freedom and social responsi
bility. Discussions on victim-blaming create
awareness of the societal conditions that set
limits to personal freedom, but also offer options
for personal choice. The health promotion prin
ciple: "making healthy choices the easy choices"
is an echo of this discussion.
The expansion of the health education frame- M
work with societal factors raised the debate on
how far health educators should be involved in
public policy and whether they should engage ir
health advocacy.
The close link between internal health edu
cation debates and the rise of the health pro
motion concept is evident. The response to thi
new concept in health education, however, dif
fered. Some adopted the label health promotion
because of its positive ring. In reaction to guilt
inducing, victim-blaming messages they now
tried to find a different style and tone. Moving
on from optimistic content, new methods were
tried; balloons and printed T-shirts were promin
ent in showing this new way of healthy living.
Some went beyond this change at the programme
level. They changed the names of journals and
organizations or established new ones. As these
arc recent events, it has yet to be observed
whether this change of name is also of
consequence to the content.
The dilemma seems to be: to join the new
movement and change the workload accordingly,
or to stick to health education, with the minor
changes, and be considered part of the
traditional forces. This is the core of the identity
crisis health educators face: uneasy feelings are
prominent in widespread discussion.

253
I

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O)

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254

H. SAAN

HEALTH PROMOTION AND HEALTH EDUCATION 255

To clarify any differentiation between health
education and health promotion we have to
focus not on shared principles but on the differ*
ence of perspectives. For health promotion to
improve health it is necessary to increase control
over the determinants of health. Somehow all
efforts by individuals and organizations have to
be orchestrated into one harmonious structure.
A health policy is the score for this effort. Many
instruments are needed to address different
aspects of the problem. Health promotion tries
to balance between choice and option, thus
combining the behavioural and societal forces.
The historical shaping of society in organiz
ations, professions, departments etc. very often
hampers the solution of today’s problems.
Therefore the keyword “intersectoral" has
become part of the health promotion trademark.
So it Is in the policy development perspective that
health promotion plays its role.
For health education the perspective is pri
marily focussed on individual behaviour, using
group and society at large as the context. This
context may support the continuous life-long
learning process; it may offer opportunities to
act on personal preferences by creating adequate
options. But the contribution from health
education, also within the framework of health
policy, is a contribution to the human capacity
for health.
So shifting from health education to health
promotion, organizations have to take into
account what shift in effort they envisage. A
serious change in organizational policy could
imply a reduction ol the number of educational
professionals and an increase in the number
of professionals in environmental sciences,
epidemiology and other health information,
administration, management and policy develop
ment. This might imply a serious change in
relation to other agencies. The organization
would also have to face the difficulties
developing an adequate health policy. Although
health education is a well developed professional
contribution to this; certainly the study of
environmental and social factors is still in its
infancy. Databases to guide interventions and to
balance situation oriented interventions with
behavioural approaches have still to be
developed. Next to that is the integration of the
traditional medical care organization into a new
health system — a serious challenge. Instruments

for intersectoral policy development are still at
the experimental stage.
Another option is to maintain the label of
health education; to focus on the human capacity
for health and actively to deepen health edu
cation. So far, development in health education
has been promising in many respects, but far
from complete. The rapid changes in scientific
knowledge, information technology and other
societal trends have to be integrated into a system
of continuous education for health.
Certainly the development of patient education
within the medical system and the link between
this information and outreaching lifestyleoriented programmes is a serious organizational
problem. In general, continuity of education is
not yet used as a fundamental principle in
designing health systems and in setting rules for
referrals. In health promotion, participation and
community development are considered to be
key issues. Health education could make a major
contribution in making policy development for
health understandable and accessible to people.

H.E.: So my question was: Am I going to be
abolished by your activities or do I have a
special role to play? How do you consider
your role?
H.P.: Well, if we stop focussing on what we
share, we could try to differentiate by
using the perspectives we are working in.
I consider it my duty to improve health by
all possible means and therefore it’s
necessary to increase control over the
determinants of health. Somehow all
efforts by individuals and organizations
have to be orchestrated into one harmoni
ous structure. Compare it to an opera:
very often the tenor is most determinant
about his personal choices and the
soprano is setting the conditions and
options to this behaviour.
H.E.: I like this linkage between cultural thinking and policy development. But how do
you consider your role?
H.P.: I’m the alto: I try to bring the two
together and I’m only hindered by all
kinds of traditional societal forces,
brought into play by the bass. But to be
serious: I consider a health policy the
score for this effort. We need many
instruments because we are addressing

I
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'

!

,
!;
!

i

complex programmes and we have to
intervene in different systems. The
historical
shaping
of
society
in
organizations, professions, governmental
departments etc. very often hampers the
recognition and solution of today's
problems. That is why "intersectoral*’ is
such a keyword for me.
H.E.: So you consider health and policy your
Field of activity. Well, that’s much larger
than my focus. It’s true I start with the
behaviour of the individual; always
referring to group forces and societal con
ditions as the context. This context may
be supportive for the continuous life long
learning process that shapes individual
behaviour. But my focus is to offer
opportunities for learning and therefore
my contribution is in the field of human
power for health. I’m not sure whether we
have enough people to keep up wiih the
rapid changes in scientific knowledge and
information technology and other societal
trends. We have yet to build a system of
continuous education for health. Cer
tainly including patient education, the
linkage of education in the medical care
system to other parts of the health edu
cation system is a challenge.
H.P.: So no more organizational and policy
activities?

H.E.: Oh, policy development for health could
not work without us. In the redesigning of
the health system we should make sure
that continuity of education and infor
mations is used as an organizational prin
ciple. And next to that we should play a
role in realising further participation:
policy development for health should be
understandable and accessible for all
people to make sure it meets their needs.
H P.: You seem to have made up your mind
about what we share and where we
differ.
H.E.: Yes, I would like to develop health edu
cation further, as a separate, but not
isolated sector. I think that is my contri
bution — to change the tune from henlth
minor to health major.

To develop health education further, as a
separate but not isolated sector, could ensure
that health educators are able to engage in an
intersectoral activity with a strong sense of
identity, a clear contribution and a great ability
to adapt to the sound of a larger orchestra. But
this presupposes virtuosity on one’s own instru
ment and a readiness to play the solo if the score
so indicates. And, sometimes, you even have to
join the composers' workshop to be sure that the
right score is produced.

ro
ro

228
health education journal

VOL 43

'.CS2&3

1984

DEBATE
Health education versus health promotion - a
practitioner’s view
Howard Seymour,
Regional Health Promotion Officer,
Mersey Regional Health Authority

Z
O

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z

-U UJ

Classified in this way. it is easy to see how :ne work of
health education officers links with the various
perceptions of health promotion. There are normally
three- ways m which health promotion is viewed, the
| RECENTLY, a darkening cloud of conflict and uncer (razzmataz^l approach. the preventive services and
tainty has enveloped the world of health education uifuiTfiafion approach, and a definition of health
The observer, sitting on the sidelines, must have been promotion which covers all ways of promoting
left in a state of bemused confusion to hear the claims people s health, including both health education
of health promoters to be particularly concerned to activities and change at a political, social and
I change political, environmental, social and economic economic level
I factors which affect health, or the health educators’
It would seem. then, that health promotion and
I claims to influence the ’hidden curriculum’, the health education are not unitary activities, but when
context in which health education occurs.
looked at m detail, from the point of view of their
It sometimes seems that the difference is best practice, all mirror various aspects of each other
illustrated by a series of dichotomies:
The definition of health promotion which aims at
the
"positive pursuit of fitness and wellbeing by
wholistic
reductionist
means
of a whole range of activities, including health
individualistic
societal
education,
legal and environmental controls and
optimistic
pessimistic
influence
on
social and economic factors" is probably
building new
eliminating old
the
most
useful
definition to follow. It is not limited to I
behaviours
behaviours
the inappropriate use of traditional health education
Which side, however, would claim to be on the activities, but can use the razzmatazz and preventive
approach when these are called for. It also has its roots
various ends of these dichotomies is not clear.
The common analysis of this situation is that some in new wave’ health educanon and can develop this
writers have seen health education and health line of approach.
When viewed from the point of view of practice. promotion as two entirely separate entities, while
others see them as overlapping. The difference both health education and health promotion seem to/
between these analyses can often be explained by the overlap in many, if not all, respects.
What. then, are the differences'? They are certainly
different backgrounds, stances and interests of the
analysts. These can usually be classified as falling into not in content There is. however, a distinct benefit to
one of the foDowing groups: the academic view; using the term health promotion’ to cover all the
the practitioner view; the concepts of health acuities covered in gaining change in people’s health 4
at individual, group, organisational and community
held.
_
level 'The term promotion’ can overcome sterile4
The academic view __________________
resides in theoretical ideas
about the meaning of education and ways of gaming ^W^ents about what is or is not education For
improvement in people's health. Interesting though example, is changing the fat content of food in
m
these arguments are1, they do not in the end help in hospital catering systems an educational activity'?
clarifying the practice of health education/promotion Whether it ^ educational or not, it most certainly has
Health educanon practices do not necessarily fit the ^^Potennal for the promouon of people’s health
The only other difference would* seem to be in terms
purest definitions of the academics.
Health education officers are involved in at least of who can practise health promotion or health
three types of health education. I have called these, for education, and the interlinked questions of who is m
want of any better titles, 'traditional', ‘educational’ control. There would seem to be an interest in health
and ’new wave’ health education. These categories Prornotion ^sin9 more outside expertise and involving
more people with a wider range of skills than at
covera very wide range of activities;
present deployed in health education. Health promo
Traditional
Information on health issues - Exhorta tion may aspire to be organised differently from the
health
tion to individuals to change
way health education is at present, but organised
education
Campaigns aimed at informing people differently to undertake the same aims
about health problems
The question of aims bungs into focus perhaps the <
Educational
Training of health professionals, etc in
health
education methods
most interesting, least talked about, but most fundaeducation
Cumculum development
mental aspect of the health education/promotion
Community health work
debate
This is the question of what we are aiming to
Group work and personal development
New Wave
Support of pressure groups, e g wom improve that is health. It is however, my contention
health
en’s groups, ethnic minority health that much of the disagreement relates to unstated,
education
groups
beliefs about what is being promoted. Again, though/
Policy change - catenng/smoking policy the argument is not distinctly between the health

DC
ixi
37

229
HEALTH EDUCATION JOURNAL VOL 43 NOS 2 & 2

1954

promoters and the health educators It is of fundamen Knowing that I can make things happen ' (control)
tal importance in both these fields to be clear about
Health promotion may lead to new and innovative'
what one is trying to improve In health education ways of organising the delivery of services to improve
circles it has been commonly found that people often health If. however, health education is relegated to
view their health at three different levels
educational health education' activities only, a
Firstly I m healthy when I ve not been ill recently serious and positive look must be taken at the future of
(disease avoidance; Secondly , irrespective of illness I health education officers and heaJth education units,
have my health if I can cope. I can deal witn what the particularly m view of their role in traditional and new
world throws at me. I perform adequately with what I. wave- health education approaches
my family and others expect of me (coping) Thirdly,
health is an ephemeral phenomenon, a perception a Reference
i Tones K Education and health promotion new direction Journaj
feeling of energy and control, ' being on top of things. o: the Institute of Heaitn zcucauon 1984 21: 121 • 129

Towards a definition of health education and health
promotion
John Catford,
Don Nutbeam,
Positive Health Team,
Wessex Regional Health Authority
THE term 'health promotion has come into common
use over the last few years, and we have been keen
supporters of this development. As a consequence
there has often been lively discussion about the inter
relationships between the terms ‘health promotion’,
health education', disease prevention' and positive
health'
The translation of a concept into a definition has its
problems. By their nature definitions are summanes,
and will inevitably be unsatisfactory. Subtleties of the
objectives and processes are often missed Neverthe
less. we think it important that some statement is
made so that there is common understanding about
these terms. Our cunent view is as follows.

Health education

• Health promotion embraces the concepts of disease
prevention as well as the notion of positive health the promotion of a sense of physical and mental
wellbeing A major emphasis is to make the healthy
choices, the easy choices Health education is a core
component, and it is unlikely that health promotion
will succeed without it
• Personal services designed specifically for health
promotion comprise
Preventive medicine services, eg immunisation,
family planning, hypertension screening and
control.
Positive health services comprising individual
and group programmes, eg smoking cessation,
keep fit. weight reduction.
• Environmental measures concern safeguarding the
physical environment and making it conducive to
health, le at home, at work, on the road, in public
places. Examples of these often traditional public
health' measures include provision of clean water,
safe sanitation, pollution control, fluoridation, fire
precautions, industnal safety measures, better road
design, non smoking areas.
• Community development normally involves the
mobilization of community resources, both human
and physical. Activities might include the formation of
self-help and pressure groups, and the development of
local facilities and services.
• Organisational development usually concerns un
plementing policies within organisations which pro
mote the health of......
staff and clients, such as the
achievement of non smoking areas, exercise and
changing facilities and healthy catering services
• Economic and regulatory activities are primarily
concerned with creating a social and economic
environment which protects or improves health
Examples include fiscal measures, legislation,
voluntary codes of practice and the widening of the
availability of services and products conducive to
health.

• Seeks to improve or protect health through
voluntary changes in behaviour as a consequence of
learning opportunities. It can include personal educa
tion and development, and mass media information
and education
• Personal education and development concerns
improving knowledge about health, offering health
risk advice, and. promoting self-esteem and self
empowerment. Examples include the opportunities
provided through teacher-pupil and doctor-patient
contacts.
• Mass media information and education tends to be
non-personal, and concerns raising public awareness,
creating a climate of opinion and offenng health risk
information and advice. It can take the form of public
relations, advertising, marketing, news information,
and distance learning projects, eg through radio.
television, newspapers, other publications
Health promotion
• Seeks to improve or protect health through
behavioural, biological, socio-economic and environ
mental changes. It can include health education, • We look forward to carrying further contributions to
personal services, environmental measures, commu the debate about health education and health promo
nity and organisational development, and economic tion Letters or bnef amcles should be sent to the
and regulatory activitives.
Editor to amve by the beginning of October.
38

*

3

75
HEALTH EDUCATION JOURNAL

VOL 44

NO 3

1985

DEBATE

To educate or promote
health?
That is the question
Jeff French
CURRENTLY a small minority of health authorities Implications
What implications does the adoption of the phrase
have decided or been advised to change the name of
health
promotion’ into a title of a worker or organisa
their health education departments to that of health
tion
entail?
Current definitions of health promotion are
promotion department, and to rename their health
education officers 'health promotion officers/advi- many and wide-ranging Activities seen to fall within
sers'. It has also been mooted that the Health the remit of health promotion include behavioural
Education Council and other health education organi change, personal education, self-empowerment,
sations should consider a change of title. Before any mass media information and education, administra
such decision is taken, I feel it would be as well to tive and legislative change, community development,
address some fundamental questions regarding preventive medicine, curative medicine, positive
health promotion. Why have some people decided health services, and so on. If we accept such
that this change of title is necessary7 What are the definitions, then to adopt the title of health promotion
implications of this decision7 And what significance officer/adviser, or health promotion organisation, is to
imply that a worker or organisation has some special
does it hold?
ability or expertise which enables them to marshal all
the above activities. This position is clearly ludicrous
Why change?
In answer to the first question a»number of for it would surely require a superman/woman to fulfil
explanations are possible. The phrase 'health promo such a role, even if it was desirable, which it is not
tion’ may be perceived as a more accurate description Surprisingly, some even go so far as to propose the
of the role carried out by health education officers development and employment of such super-people
It is evident that health promotion, by its very
Health promotion may be viewed by some as a more
nature,
cannot become the preserve of any one group
'scientific' activity than health education, and more
readily amenable to quantitative evaluation. Some of workers, and that any attempt to professionalise
may favour health promotion because it sounds like an health promoton m this way would lead to the
up-market high-profile approach to health education, fulfillment of one of the World Health Organisation's
and obviously this type of approach is both much fears, namely “there is a danger that health promotion
easier to understand and also more readily seen to be will be appropriated by one professional group and
done than many cunent approaches to health educa made a field of specialisation to the exclusion of other
tion. All these reasons have their base in a dissatisfac professionals and lay people. To increase control over
tion with existing approaches to health education. But their own health, the public require a greater share in
is this sufficient grounds for its rejection? I think not. all resources by professionals and government
Health promotion demands widespread participa
very few district health authonties have actually
tion.
Consequently it is necessary to involve adminis
established fully staffed and funded health education
trators.
opinion leaders, community networks, politi
units. In fact, such units can be counted on one hand
cians.
voluntary
organisations, individuals and others.
Is it not. then, a little premature to abandon a concept
It
is
only
in
this
way that true health promotion will
and a way of working which has never been funded to
result. One group of workers cannot encompass the
a position where it can begin to work effectively?
In addition, some workers in health education and range of skills or exert the necessary influence to bring
community medicine view health promotion as an about health promotion. However, those concerned
attractive enough field to fight over, leading to a with health education can and do educate this wide
power struggle between HEOs and community physi spectrum of influence about the need and process oi
cians. This, of course, is a very negative view, and health promotion. This is the role of health education,
statements like “we are really changing our name to to stimulate and facilitate health promotion, not to
lay a claim to this way of working" will only serve to dominate it. Those of us who are lucky to live in a
divide the very people who through co-operation broadly democratic society and cherish the concept of
could and should be prime rfiovers for health democracy, should oppose any professional group
which seeks to annex health promotion, because
promotion.
115
4

76
health education journal VOL 44 NO 3 1985

01

te

should

Promouon’ Most certainly not. I fully endorse the
WHO definition of health promotion2, and view health
promotion as the means through which the health of
0Ufr P?p^at,on can be improved. I also commend the
establishment at district and regional level of multi
disciplinary health promotion teams Health promo
tion is the responsibility of all those who are con
cerned to bring about the improvement of health
Health education is an aspect of health promotion,
and
its role is to maximise the involvement m health
promouon9wSaJpe^^o1 md^03110" t0 health
promotion, as well as providing people with informa
tion. skills and experiences through which they can
exercise a greater degree of control of their own
health. I fundamentally reject the notion that health
promotion is or could be an area over which one
professional group could or should dominate Health
promotion should be seen as a banner under which a
wide variety of people can gather to work for the
enhancement of people s health. It is both illogical and
counterproductive for any one group to appropriate
health promotion, and I therefore commend the HEC
and the vast majority of organisations and health
education units with the sense to refrain from
incorporating the phrase health promotion' into their
titles, which by the very act of doing so negates the

~

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assBrr""
ssaxa xeahty s

References
1.
HmS) &k?ce?e26lL8P2rOmOn°n m
2
3

health education which h ma^S medla approaches of
of limited value if used m iSS
t0 66
Whither health promotion?
Am I, therefore, advocating the rejection of health

reorgan,sed NHS

^Zr^^!^nPrOrniODOr] A dlscussl0n document on the
650 of
pracllce
Copenhagen.
July s1984
Peter H. Pocket Treasury
Great Quotations
Reader
Digest

4

Williams G HeaJth promotion - canng concern or shrk
salesmanship’Journal of Medical Ethics 1984; 10: 191-195

*

1S DlsUlct HeaJth Education Officer for
the Mid-Downs Health Authority

mental health

Education in human relatioi
with mental handj
—icaiK

e

S61 Malin' BA’ DiPASSA . MPhil, PhD
Senior Lecturer
Sheffield City Polytechnic
G Camp'On. SRNJjgMT
Health Education Officer^^
Lincoln

its
ial
f'-- ylta
are
i4;ore
; i-rs are

lElauvu.------- _ -

teachin9 within health educa-

116

_

-v

'tan

workers into schools to develop this are^HumM
mln?»nS1^PS ®ducation « important in enabling
d^^Ily>^andLCapped P^Pie to survive indepen”
dently within the community.
4

*

299

HEALTH EDUCATION
SPECIAL
Mid-section of GGD-News, Moy 1993
on the occasion of the
International Conference on Health Education
in Amsterdam, May 24th - 26th, 1993

Editors
Mrs. N. Siderakis-van Tankeren
Mrs. N.E. Warmenhoven

Translators
Mrs. F. Siderakis-de Leng
Mrs. J. Wouters
Mrs. N.E. Warmenhoven

1

300

Contents
1. Introduction
2. Prevention in the Netherlands

3

J. struggling for Quality
4. Cooperation between national"

5

regional Health Education .
P ek°lrfl'nfo|r?1ation by Municipal
Public Health Services
6. Dear Customers
7. Living Together
8. Peer Education on AIDS ....

2
20

4

8
12
14
16
19

301

Introduction
This Health Education Special gives a
helicopter-view of some recent develop
ments in the field of Health Education in
The Netherlands.
To start with, an overview is given of the
organization of Health Care and Pre
vention in The Netherlands. The subse
quent chapters deal with some important
developments in Health Education: the
quest for quality; the need for cooperation between national and regional or
ganizations; information directly aimed
at the public and customer-orientation.
In the last two articles, two approaches
to AIDS-education are described. The
fact that it is difficult to prove the effect of
Health Education is one of the major
problems that Health Education faces.
The effect on Public Health shows only

after a long period of time, after using
many educational methods and chan
nels; locally, regionally and nationally.
For instance, the number of road acci
dents caused by alcohol abuse has
decreased over the last years. Many
organizations have contributed to this
effect, although the importance of the
separate contributions is difficult to distinguish.
We hope this special will add to a better
understanding of the essence of the
work of Health Education officers, but
also of the challenges they have to meet.
This being a journal of the Municipal
Public Health Ser/ices, these organiza
tions are actors in most of the chapters.
We hope the reader will forgive us for
this immodesty.

3

302

Prevention in The Netherlands
Assuming that an T
J
English
mid-section of GGD-News

will be read by people
outside the Netherlands,
it seems appropriate to
give a brief overview of the

Naturally, the division between these
different types of care are more or less
fluent. The Municipal Public Health Ser
vices have tasks that are not basic health
care (ambulance services, for example);
GP's and district____ _
r
t nurses have preventive
tasks as well as curative tasks.

Dutch Health Care System
in general and health
education/prevention
in particular.

Mrs. N.E. Warmenhoven

The Dutch Health Care System
For the last 20 years, the Health Care
System in the Netherlands has operated
according to the echelon-model of basic
care, first line care and second line care.
Basic care could be described as being
nearest to the consumers ordinary sur
roundings, and easiest to reach (i.e.
without a built-in threshold).
Organizations belonging to this level
deal with preventive health care and
health promotion (vaccinations, anteand postnatal care, surveillance of infec
tious diseases, screening for breast
cancer and so on). At least part of their
target population consists of healthy
people. Municipal Public Health Servi
ces (the Dutch abbreviation is GGD) and
Home Care Associations are — mainly —
concerned with basic health care.
General practitioners, dentists, physio
therapists, pharmacists, district nurses
etcetera belong to the so called 'first line
health care'. The GP serves as the king
pin for this type of care; without whose
referral people are not admitted to most
other disciplines in first or second line
care. In comparison to basic health
care, first line health care generally
deals with people who do have a - be it
minor - problem. However, it still focu
ses on patients in their own surroun
dings. Together, 'basic health care' and
first line health care' may be compared
to the English concept of primary health
care.
Second line health care' consists of
general or specialised hospitals and
institutions, like nursing homes. Patients
are only admitted to this type of care on
referral by their GP.

4

Health Education and Prevention
After the general view of the Dutch
Health Care System we will now deal
W|th different organizations in the field
of prevention/health education in more
detail. Organizations may operate on a
national or regional level, and they may
either be concerned with specific health
topics, or with health promotion/prevention in general.
— Regional Institutes for Ambulatory
Mental Health Care (RIAGG) offer
ambulatory care for psychological
and psychiatric disorders. They are
also concerned with the prevention of
these disorders; they offer courses for
the elderly in order to prevent loneliness; courses for teachers to signalize
sexual abuse of children etcetera.
There are about 60 RIAGG's throughout the country.
- (Regional) Consultation Offices for
Alcohol and Drugs [CAD] again have
curative as well as preventive tasks.
They have projects for school, trai
nings for intermediaries like GP's et
cetera. The Netherlands have about

20 CAD's.
- Home Care Associations offer home
care and youth health care for 0-4
year-olds. Health promotion and pa
tient education are integrated parts of
care. Often group activities like cour
ses how to stop smoking, and nutriti
on education are organized.
- Local and regional patient organiza
tions offer patient education and in
formation about health care facilities
in the region.
- Many hospitals are professionalising
their patient-education and contract
health education officers to promote
this. These people may offer support
to the doctors and nurses in dealing
with patient education; an increasing
number of hospitals set up a patient
information desk.
- Municipal Public Health Services
(GGD's) have a wide variety of tasks
in what we call 'collective preven
tion'. Under the Collective Prevention
Act of 1991 GGD's have epidemiolo-

gical tasks, they are responsible for
the setup, execution and coordination
of prevention programmes and for the
monitoring of municipal policy deci
sions in aspects of health.
Although there has only been a cove
ring network of GGD's (60 in total)
since about 5 years, some Services
exist for over 75 years. In fact, the
term 'municipal' is not completely
right because a Municipal Public Health
Service is usually a 'joint venture' be
tween many Municipalities (about 10
on average).
It is evident that these regional organiza
tions are compelled to cooperate. More
and more, the trend is not to compete but
to join hands, coordinate efforts and tc ' '
to offer a package of preventive activ.
that is well fitted to the needs of the
region.
There is not only cooperation amongst
different regional organizations, but also
between regional and nationalorganizations. There are many national institutions
or foundations focused on different
health-topics; the Dutch Heart Founda
tion, Consumer Safety Foundation and
Cancer Society are just a few examples.
Apart from organising national cam
paigns (which the regional organizations
can follow-up with regional activities)
these national organizations support regional activities, give specific facts, pro
duce health education material etcetera.
Then there are national organizations
that offer general support on the topic of
prevention, health education an^zor
health promotion. A well known exc
le
is The National Centre of Health Educa
tion, but the associations of the different
types of organizations are also active in

this field.
Last but not least the Dutch government
aims at providing the right conditions for
prevention and health education. The
current trend to make prevention finan
cially dependent on market-mechanisms
of demand and supply, and to decentralise funds for prevention, is> cause for
some worry.

Mrs. N.E. Warmenhoven works for
the Association of Municipal Public
Health Services in Utrecht, in several
supportive projects for Municipal
Public Health Services (GGD's).

303
-

Struggling for Quality
Just fashion or a serious attempt to aim

at improvement of health education?
Quality is 'in fashion';

Introduction

recently also started a project to improve
it seems as if every
The fact that everyone is discussing
quality control of the Municipal Public
self-respecting organization
9ual,tyr and that there are different
Health Services (GGD's) as a whole
'finds
’
'it has to spend some motives to exercise quality control brings
('GGD's on their way to the year 2000').
along the risk that all this attention is too
Naturally, the LVGGD will see to it that
time on quality control.
readily interpreted as a symptom of
the results of both routes can be linked.
For the Municipal Public
fashion. In our supportive project for
Health Services however it
health Education by GGD's (Municipal
The start
Public Health Services), we started wor
Health Education is a relatively young
is not just a trend.
king on quality development, too.
discipline in the world of the Municipal
This article tells you However, we do not intend to get stuck
Public Health Services. Often it is still
why not.
in a temporary trend. If we actually want
searching for its place in the organiza
to contribute to the improvement of
tion. On the one hand, the WCPV (Act
Health Education
by Municipal
Public
on Collective
Prevention in
Public Health,
Health Services, we must take a critical
1989) emphasizes the Health Education
Mrs. A. Veldhuizen
view of our endeavours. This means we
tasks of the Public Health Services; on
must make clear why and in what way
the other hand, these tasks have not
we want to engage in quality developbeen clearly defined and testcriteria are
ment. Working in our own 'quality pro lacking.
cess', this midsection on Health Educa
Besides, from a societal viewpoint, the
tion gives us a good opportunity to
whole field of Health Education (within
welcome the reader to our 'shop'.
and outside Municipal Public Health
Services) has recently been a subject of
critical discussion. By order of the go
vernment an evaluation was made of the
M/
Kt-fT
out.
results of ten years of financial support of
Health Education ('the Bakkenist report').
The Dutch Association for Prevention
and Health Education (NVPG) recently
found that Health Education officers find
their career prospects unpromising. Ma
ny of those who are now working as
Health Education officer hope to occupy
another position in five years time.
Altogether, there seem to be enough
reasons to pay attention to the quality of
Health Education. Not so much because
there is much reason to worry (as was
stated in the editorial, there was always
a great deal of effort by Health Educa
tion officers to perform within clear
structures as well as systematically), but
to make the essence and effect of Health
Education clear and measurable to the
workers themselves, as well as to their
critics.
In order to formulate norms and criteria,
This paper is concerned mainly with
it is essential to start a discussion on
quality control of Health Education by
quality. We thought thatf a quality
Municipal Public Health Services. Some
conference
conference would
would serve
serve this purpose.
Mrs. A. Veldhuizen works with
referrals are made to the quality control
More than a year ago we took the
the Association of Municipal Public
of Health Education in general; the
initiative to organize such a conferen
Health Services and is project-director
National Centre for Health Education
ce.11 The conference may be considered
of a supportive project for Health
plays an important part in this respect.
successful in its purpose to start the
Education by Municipal Public Health
The LVGGD (National Association of
discussion on quality between Health
Services.
Municipal Public Health Services) has
Education officers and their manage-

I tri'C A

onct.

5

304
ments in Municipal Public Health Servi
ces. About 1 10 people participated in
the programme; a starting-point for a
quality process was effectuated.

A joint effort

process was translated into action by
organizing several sectoral meetings in
which we developed a communal vision
with regard to the chosen themes. This
coordinated voicing of one vision pro
ved to be a great asset, for we could
strike an unanimous and consistent note
in the work conferences and, later on, at
the national conference.
On June 19, 1992, the First National
Quality Conference was held at Ede.
The results of the work conferences were
commented on the same day by repre
sentatives from different sectors, in addi
tion to a number of national speakers on
quality. The most important conclusions
of that day were:
• pay more attention to 'customers'
of Health Education;
• work on standardization;
• use the quality circle;
• use models and experiences from
elsewhere.
It struck us that the speakers of the
different sectors, except for our own,
gave their personal reactions rather than
voicing coordinated visions of their sec
tor. We were slightly disappointed with
this outcome. Partly on account of the
results of the nation-wide process, we
decided to pay attention first and fore
most to our own quality process for
Municipal Public Health Services
(GGD's).

In 1 989, the National Council of Public
Health (a governmental advisory board
on public health) wrote a report 'Deve
lopment of Health Education'which was
offered to the parliamentary undersecretary for Welfare and Public Health,
Simons. This advice deals mainly with
the conditions that are needed for the
enhancement of Health Education.
Thereupon, Simons asked the National
Centre for Health Education to make a
nationwide, overall action-programme
for the improvement of the quality of
Health Education.
This action-programme was shaped into
an overall quality process of the Natio
nal Centre for Health Education. This
process concerns not only Municipal
Public Health Services, but all organiza
tions concerned with Health Education.
Within that process, a first national
conference was planned in June 1 992.
In preparing this conference, several
Health Education officers from Munici
pal Public Health Services, who were
involved in our own process have been
approached to contribute. This contribu
tion included participation in a number
of preliminary work-conferences on the
following themes (adopt?d from the con
Continuation of our
ceptual framework of the National
own quality process
Council of Public Health):
In the autumn of 1 992 we designed,
• expertise;
together with a small working-group
• professional code;
(consisting of Health Education officers
« effectiveness;
and managers of GGD's), a workscheme
for those activities that were to be reali
organization;
• financing;
zed before the termination of our sup
• information.
portive project for Health Education by
These work conferences were attended
GGD's (Municipal Public Health Servi
by Health Education officers and pre
ces), January 1, 1994. Because it pro
ves difficult to involve people intensely
vention workers from all national and
regional Health Education and preven
on a more or less voluntary basis it was
decided that two members of the project
tion sectors.
team give 'impulses' which are subse
In our project for Municipal Public Health
quently discussed in a wider context.
Services we discussed the request to
The working-group performs an essen
partcipate, and, now that quality of
tial task in that it supplies (concept)
Health Education is subject of nation
products with comment, suggestions,
wide discussion, we decided to make a
and/or additons on call.
contribution not only for the benefit of
The work-scheme contained the follo
Health Education in Municipal Public
Health Services, but also to strengthen
wing intentions:
• standardizing the Health Education
the national position of Health Educa
tion. This choice implied, in the light of
method;
• an impulse to a system of peer review;
our project, that we decided to coordi
nate efforts and to invest (temporarily) in
• describing the profile of the Health
Education task, and derived from that;
e large-scale national process directed
• describing the profile of a Health
by the National Centre for Health Edu
Education professional.
cation. The contribution from our quality

6

1. Standardization of the
Health Education method
In forementioned advice report to the
government (the so<alled 'Bakkenist
report') a flaw in Dutch Health Edu
cation was pinpointed; the 'primary
process' of Health Education is not
clear. The report stated that Health
Education should indicate what pro
ducts or services they produce; what
the essence of it is; what purpose it
serves and how services are effec
ted; the knowledge and proficiency
that are required and who makes use
of these services.
Every service is preceded by a wor
king (or implementing) process. This
process consists of different phases
of methodical/technical qualities
needed to carry out the order accura
tely on one hand; on the other hand it
consists of stages of negotiation with
the client about the nature of the
activities involved and the way the
order is placed into an organizatio
nal context. Both processes will have
to be passed through in order to gain
a clear view of the 'primary process'.
At this moment we are putting the
final touches to a description of such
a (conceptual) 'standard working

method'.
2. Starting a system
of peer review
We intend to make an experimental
start with setting up and putting into
effect a system of peer review.
By starting one or two experimental
groups, we propose to gain expe
rience with quality improvement at
the workplace.
The idea of peer review is that proff
sionals (Health Education officers u.
this case) are competent to assess
good service themselves and that
they are capable of developing com
munal standards among themselves.
The aim is to realize measurable
improvements according to prede
termined criteria.
The first one or two experimental
groups are to meet about six times
before summertime. The groups will
each be presided by a member of the
Health Education supportive project,
who will also take care of the minutes
of these meetings. The evaluation of
this plan and the experience of the
participants will provide us with im
portant arguments whether or not to
introduce a similar system among all
Health Education officers. The results
will also be used for the nation-wide

305
quality process to see whether peer
review can be introduced in other
sectors as well.
3. Describing the profile
of the Health Education
profession(al)
Finally, we aim to describe the profi
le of the Health Education profession
for Municipal Public Health Services
before the end of this year. To do this
we intend to make use of the 'quality
profile of Health Education' that was
drafted by the Chief Medical Inspec
tion (GHI) and has yet to be publis
hed this year.
It will be integrated with 'quality
profiles' for epidemiology, youth
health etcetera.
One of the results of our own 1 992
quality conference was that the Mu
nicipal Public Health Services have
been approached by the GHI to
contribute to the realization of a GHI
quality profile.

IIDDEN

In our project we want to use this quality
profile to deduct from it the requirements
that are to be met by the Health Educa
tion officer. This provides the Municipal
Public Health Services with an instru
ment for selection of applicants and
career-planning of Health Education of
ficers.
The above mentioned Dutch Association
for Prevention and Health Education has
also taken initiatives to work on a profile
and a professional code for Health
Education/prevention this year. In our
capacity as a supportive project, we will
present the results of our own quality
process to the Dutch Association in the
hope of making a fruitful contribution.

Conclusion
In the autumn of 1 993, we will have to
make up the final state of affairs with
regard to the progress of our Health
Education quality process. We will do
our utmost to guarantee the progress
and the continuity after our supportive

project ends, by transferring relevant
tasks to the Association of Municipal
Public Health Services, its Platform of
Health Education officers and its Com
mittee of Health Education.
We will continue to cooperate - within
limits of efficiency and effectiveness with other parties concerned.
A progress report will be published in
the form of an article in this journal in
autumn.

A summary account of our quality
conference, as well as annual reports
and workschemes of the supportive
project are available (all in Dutch)
on application:
Stichting Projecten VDB
Postbox 85.301
3508 AH UTRECHT
telephonenumber (0)30 - 523004

prik van de week

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7

306

Cooperation between national
and regional Health Education
Friction between ideals and reality
In this article the authors
discuss how theories about

extension science and the

I p to about 10 years ago national,
Ilocal and regional health educa-

tion °r9°nizati°ns 7°rked a/on9-

.
r. .
.
change ot behaviour can be
used by national and regional

side one
another rather than with one
<
another.
another. This
This was certainly not beneficial to the efficiency and effectiveness of

organizations in health

health education.
In 1982 some prominent people in the
world of health education in the Nether
lands got together and wrote a discus
sion paper to put this issue high on the
professional agenda (de Haes, ed.,
1 982). Now, ten years later the discus
sion is more relevant than ever.

education. To do this, they

use their experience in a
joint project between the

Netherlands Heart Foundation
and the National Association
of Municipal Public Health

Services. Using six different

approaches to cooperation, a
description is given of the
strengths and weaknesses of

both organizations.
Finally recommendations are
made to improve the coopera

tion and the division of tasks
between national and local

health promotion activities.

Mrs. M.P.A. Bouman,
Mrs. M. van Houten

Mrs. M.P.A. Bouman is Senior Advisor
on Health Education Policy with the
Netherlands Heart Foundation.
Mrs. M. van Houten is coordinator of
the Association of Municipal Public
Health Services and a member of the
editorial board of GGD-News.

8

u
I
I

Focus on structure or function?
In a recent government note 'Prevention
Policy for Public Health' (WVC, 1992)
the government stresses the importance
of the direction of prevention and health
education on a national level. The go
vernment itself is aiming at powerful
central control, and has the intention to
encourage closer cooperation, if not
mergers, between national organiza
tions in the field of Health Promotion,
Health Education and Prevention. This is
rto
.j now health
rather striking/because up
policy was m<lainly influenced by providing structures; apparently the emphasis
has now shifted (with the withdrawal of
the Health Care Facilities Act at the end
of the eighties) to directing functions in
the area of prevention, care and cure.
Almost everyone will agree that better
cooperation and better coordination is
necessary between organizations con
cerned with prevention and health edu
cation. Although a great deal of pro
gress has certainly been made, efficien
cy, effectiveness and quality can still be
improved by strong cooperation. In any
v. the
...<w time when the sky was the limit
case
definitely belongs to the past. Where
until recently we could talk of a friendly,
non-committal discussion about cooperation, a period of serious measures and
negotiations has now dawned.
History has taught us that forcing parties
to cooperate, or creating special cooperative structures does not in itself lead to
effective cooperation. It has to be a 'win

win' situation for all parties concerned.
At least two approaches are important
here: what we can learn from the theo
ries about behavioral change (which is
what Health Education aims at) and what
we know - largely on the basis of practi
cal experience - about the strengths and
weaknesses of national, regional and
local Health Education organizations.
These approaches are examined in mo
re detail below.
Approach from theory
The habit-forming and behavioral chan
ge on which Health Education focuses is
a complicated process that often takes
place step by step.
The important theories in this respect are
often deduced from social marketing
(including lefebre, 1 992), the theory of
diffusion of innovation (Rogers, 1 983)
and the phases of behavioral change
(amongst others: Kok, 1985 and Mc
Guire, 1985)

Social marketing

Social marketing is helpful in socalled
target
group
, segmentation: recognizing
different groups in the population with
comparable
parable characteristics and needs,
1 J
and then deciding on a strategy. **People
>rks
live in all kinds of different nt
(local com
family, the workplace etcetera), each
’ 5 own culture and associated
with its
norms and values, all of which have their
particular influence on that individual. If
health education activities are set up
without taking into account the social
networks that are important to a given
individual, it will be difficult for people to
change their behaviour against the
stream. Equally, the influence of social
networks, including the mechanism of
social control, can be put to good use to
initiate and maintain a process of behavioral change,

Diffusion of innovations
Encouraging a healthy lifestyle (for exam
pie safe sex as part of the AIDS cam
patgn) can be seen as a process of

307
diffusion of innovations in society. Ro
gers points out that it can take a long
time before everyone in society mpkes a
given change and that changes in socie
ty take place in certain phases.
At first there is always a small group of
people who are at the forefront of chan
ge: the innovators. These people are the
trendsetters; they are less dependent on
public information and obtain their infor
mation largely by themselves. Health
Education officers sooner need the inno

vators in order to spread their ideas.
The next group consists of early adop
ters, the ones who quickly adopt a
change. They are people who are very
susceptible to the national media and to
new information. This is a group that can
easily be reached through the mass
media method.
It is much more difficult to reach what
you might call the large majority. For
them
—i a more inter-personal approach is
needed.
The remaining group consists of 'lag
gards' , sometimes called 'deprived' or
'socially excluded' people, who gene
rally live quite isolated lives, have little
contact with the media and few opportu
nities to absorb new things. They defini
tely require their own specific approach,
especially since many health risks threa
ten these groups most.

!n view of the theories mentioned above
and their analysis of the major cam

paigns Green and McAlister argue for a
close interaction between the mass me
dia approach and the more interpersonal
community approach, in all phases of
the process of behavioral change.
In the diagram below they indicate
where the supporting links can be made
in every phase.
Assuming for the moment that the strength
of national health education organiza
tions lies primarily in their use of the
mass media method, and that the strength
of the /oca/and regional organizations
lies in the more personal community
approach, the schematic survey presen
ted by Green and McAlister offers the
necessary links to enable us to create a
wellbalanced range of health education
activities.

ments: interest, knowledge and under
standing, weighing up the advantages
and disadvantages, the desire to chan
ge, and the skill to actually do so and to
go on doing so.

The ideal model
In the eighties Green and McAlister
carried out comparative research into
cooperation between national and local
organizations in a number of major
cardio-vascular disease
campaigns
(Green and McAlister, 1984).
Campaigns appeared to be more suc
cessful as the population is more invol
ved in the setting up and implementation
of the various activities. A community
based approach to providing informa
tion proved to be very promising. Not
the individual but the community in
which he lives (district, village, region) is
the starting point.

• monitoring and programming
research;
• network development and lobbying;
• provision of information and
documentation;
• professional development.
Developing strategies
Working as an independent national

organization on a specific theme of
health education (e.g. cardio-vascular
disease, nutrition, asthma) it is vital to
constantly check the needs and wishes
of the target group. The 'helicopter view'
which many national organizations ha
ve is certainly sufficient for the general
picture but not for the refinement of the
message and the accurate adjustment of

Features of Communication and Community,
Supporting Phases of Individual Response to Mass Media

Phase in Psychological
Process of change

Supporting Features
of the Communication

Supporting Features
of the Community

1. Exposure

Use of most popular
media of communication,
program repetition

Social setting with
access to media

2. Attention

Message relevance,
attractiveness, novelty,
drama, humor and suspense

Interest of family,
peers and other
significant persons

3. Comprehension

Use of simple concepts
with illustration and
analogy

Group discussion and
feedback, questions
and-answer sessions

4. Belief

Expert and trustworthy
sources, counterarguments
refuted

Direct persuasion and
social influence, actions
of informal leaders

5. Decision

Display of incentives and
values of different
consequences, of action,
messages enhancing self
confidence

Group decision-making,
public commitments, re
peated encouragements
wich build selfconfidence

6. Learning

Step-by-step demonstra
tions, guides for practice
and feedback, repetition

Demonstration and
auided practice with
feedback and continued
confidence, advice and
directed assistance

Behavioral change step by step
We know from the theories on behavio
ral change that people have to go
through a number of stages to finally
change their behavior and maintain it.
Although behavioral change does not
always follow the same fixed pattern
there are a number of important ele

• Developing strategies;
• developing, testing and distributing
policy instruments;

(Green and McAllister, 1984)

Cooperation can and

must be improved
Keeping the theoretical insights mentio
ned in the back of our mind we return to
the strengths and weaknesses of the
national, local and regional organiza
tions and the means of improving their
cooperation.
Six aspects will be reviewed:

supply and demand. By cooperating
with regional organizations national or

ganizations can pick up signals from
everyday experience (regional organi
zations often have a better view of these
because of their closer relationship with
the public).
National organizations which want to
combine their mass media activities with

9

308
o community approach cannot ignore
regional and local organizations. To put
it more strongly, without them there is
barely a chance of successfully mobili
sing the population. Regional activities
and acceptance of the campaign by
regional actors are at least as important
as the production and development of the
mass media components in the strategy.
However, national organiza
tions are often too easily satis
fied with any kind of regional
follow-up, without there being

especially for (regional prevention of)
cardio-vascular diseases at the LVGGD.

Developing, testing and
distributing instruments
In the last few years many national
organizations have not only developed
campaigns for the general public but
also programmes focused on target-

developed with the aim of introducing it
on a national level once its effectiveness
has been proven.

National campaigns and
regional follow-up
National organizations often have more
resources to their disposal than regional
organizations when it comes to develo
ping and setting up massmedial national health educa

tion campaigns.
Making use of a major adver
any question of previous agree
tising agency, obtaining time
ment on the form and content
UDDENj
on radio and television or
prik van de week
of activities, as Green and
getting a major article in the
McAlister - amongst others national press are feasible
argue for.
options for them. They often
Preliminary research, supporhave good contacts with the
g activities and planning of
press and the media, in many
i^cal and regional follow-up
cases because the journalists
activities are often the last
call on them to provide infor
items in the planning of the
mation and background do
campaign.
cumentation. However, such
Good interaction is only pos
a nationally organised cam
sible and practicable if there
paign or nationally produced
is cooperation in an early
s
/
educational material is inevi
ms
stage and an opportunity for
tably directed at an average
|
both sides to influence the
member of the population.
final strategy. To really work
Health Education, as has al
o
3
together and create a 'win
ready been mentioned, beco
win' relationship a lot more is
mes more effective when
samen werken aan een gezond bestaan
o
needed than just theoretical
target-groups are segmented,
groups such as school-populations, em
notions or business-like facts. In particuand methods of health education adjus
lar an open attitude to each other and
ployees, social and cultural work, and
ted for each segment. For this reason the
good insight in each other's possibilities
concept of 'pre-fabrication' has been
the like. Mass media like national televi
is important. At the same time expectadeveloped. This means that a national
sion are less suitable for such an op
tions about each party's contribution to
proach; it is necessary to develop me
organization like the Heart Foundation
the joint venture must be realistic and not
provides an outline for a brochure, a
thods and materials to use in a regional
too high.
poster or a video, and the regional
setting. In local and regional organiza
jhods of work and working cultures
organization can then add its own regio
tions there usually is a great deal of
in national and regional organizations
nal colouring and content (the Swiss
practical, methodological experience
differ from one another, in the way
with this. Regional Health Education
cheese proposal).
decisions are made as well as in the way
officers> are used to adapting available
An important problem is the great num
formal and informal consultation is struc
information for everyday use and in
ber of different national campaigns,
tured. If both sides are prepared to
each with its own specific subject (such
doing so to focus on different targetrespect each other then a great deal will
as smoking, alcohol, fat, osteoporosis),
groups. Cooperation seems logical.
have been gained. Municipalities and
It will often be useful to first set up an
while ata local level organizations try to
their Municipal Public Health Services
work on the basis of an integrated,
experiment on a small scale before
(GGD's) have a legal responsibility to
lifestyle approach (where different sub
introducing an approach on national
enhance cooperation and to coordinate
level. Such pilot studies can very well be
jects are dealt with in relation to one
activities in the field of health education
another). Good planning which takes
carried out in a region.
and prevention in their area.. Coopera~
both the scheduling and content of cam
It is desirable for national organizations
ting with national organizations they
paigns into account would be an impor
to develop ways of subsidising this.
can act as a kind of pivot in the area and
tant step forwards. A useful aid in this
Obviously a well executed and well
promote regional follow-up.
evaluated experiment can save ai lot of
respect is the 'campaign diary' compiFor this reason, the Dutch Heart Founda
led since the end of 1991 by the Natio
money and effort. A good exam|ple of
tion (NHS) and the National Association
nal Centre for Health Education (as a
this strategy is the cooperation between
of Municipal Public Health Services
regular feature in its journal 'Gezondthe Association of Municipal Public
(LVGGD) have decided to encourage
heidsvoorlichting'). Some recent exam
Health Services (LVGGD) and the Dutch

FAST FOOD, FAST

i ©ti

i

c
.munal strategy development and
implementation through a four-year joint
project. During this project, the Heart
Foundation finances a staff member

Asthma Fund.
In a two-year experimental project, a
method of providing information for
groups of children with Asthma is being

ples of successful cooperation are the
'Stop Smoking!' campaign and the
'Watch your Fat-intake!' campaign.
The former, set up by the Foundation for

i

309
Smoking and Health (STIVORO), Featu
red a national television campaign which
was followed throughout the whole
country by Stop Smoking courses offe
red by Municipal Public Health Services
and home-care organizations.
The Watch your Fat-intake' campaign

organised by the Board of Healthy Nutri
tion (SGV) made use of striking televi
sion advertisements followed by local
activities such as projects in supermarkets, week-themes on eating habits where
people could get information from t.',^
the
information centres at the GGD, and
courses about healthy eating by the
home-care organizations.

.

onitormg and

programming research
National health education organizations
tocus on different themes, but choose
similar strategies. They are therefore all
interested in results of research about
subjects such as the following:
• Development and evaluation of inter
action between national and regional

activities;
• relation between health education and
other measures such as policy, legisla
tion, facilities;
• the possibilities of gift-wrapping'
health education, into popular soap
series for example.
National organizations can learn from
the results of each other's research.
They can also try to put efforts and funds
together and set up a joint research
programme, together with regional or
ganizations, universities and institutions
like the National Centre for Health Edu
cation and the Netherlands School of
Public Health. Maybe there could even
be a special chair at the university.

Information and
documentation function
A national thematic organization is specialised in one subject or one aspect of
providing health education, for example
cardio-vascular diseases, asthma or can
cer. They have the best expertise in that
area at their disposal. One of the tasks
of a local or regional organization such
as a Municipal Public Health Service
(GGD) is to support and carry out va
rious activitiies in the field of Health
Educational and prevention. It is absolu
tely impossible for GGD to be equally
well informed and well documented on
all possible subjects. It obviously makes
sense to call on the relevant national
organizations to provide this expertise.
This function as a provider of informa

tion can be extended.

In the context of the cooperation be
tween the Netherlands Heart Founda
tion (NHS) and the Association of Muni
cipal Public Health Centres, for example,
there are plans to collect the most relevant
facts and insights into cardio-vascular
disease (and its prevention), to publish
them as factsheets and on floppy discs,
and to periodically update them. On the
other hand it is not easy for a national
wuium a yt
organization to obtain a good view of
all the local and regional I prevention

activities in its specific area of work.
They can however benefit from the Acti
vity Registration System run by the Na
tional Centre of Health Education in
which all the registered local, regional
and national health education initiatives
are recorded. Municipal Public Health
Centres play an active role in this respect.

Professional development
When providing information the accura
cy of the message is extremely important.
Out-dated information or inaccurate ad
vice can be damaging. Health Education
officers will have to regularly re-train
and update their skills. Because of their
expertise national organizations can
promote this by organizing or contribu
ting to congresses, workshops or trai
ning modules.

Development
of networks and lobbies
Health Education on its own is a rather
weak preventive measure and needs to
be supported by legislation and facilities. Lobbying for a political climate that
enhances Health Promotion is only suc
cessful! when there is some degree of
authority and political influence.
On the basis of their expertise national
organizations in Health Education often
have authority on particular subjects
and can thereby exercise their influence.
It is obvious that local and regional
politics should not be forgotten either.
Through their close ties with local go-

vernment (municipalities) the Municipal
Public Health Services are the obvious
partners when it comes to influencing
local policy.
National and regional coordination will
strengthen that effect. In the diagram
below the main strengths of national and
regional organizations (in particular the
Municipal Public Health Services) are
summarized.

Conclusions
From the viewpoint of Health Education
the need for cooperation is obvious. The
quality of Health Education in national
campaigns has clearly improved, and
methods and materials are more often
tried out beforehand and developed in
cooperation with people working in the
field. The content of the message in
advertising campaigns has become more
varied and focuses more on a lifestyle
approach. In most of the national mass
media campaigns set up in the last few
years a real effort has been made to set
up some kind of more personal regional
follow-up. New coalitions that have been
formed in the Steering Group for Healthy
Nutrition (Stuurgroep voor Goede Voeding) with industry, hotel and catering,
the prevention sector and the govern
ment, offer good prospects for the desi
red community approach. Cooperative
projects such as those that already exist
between the D"tch Heart Foundation
and the Asthma Fund on one hand, and
Municipal Public Health Services on the
other hand serve as an example for
other national health education organi
zations looking for a more structural
form of cooperation on the local/regio
nal level.
The time for talking about the desirability
of cooperation has long passed. It is
now a matter of adopting a pragmatic
attitude, of making agreements to work
together, of re-allocating budgets and,
with the courage to look beyond the
boundaries of one's own organization,
of getting down to working together.

Summary of the main strengths of national and regional
organizations (in particular Municipal Public Health Services)

Regional or^amxation
1. topical expertise
2. mass media approach
3. prefabneation
4. projects/campaigns
5. centre of information
6. intervention model
7. re-training and updating
8. research funding
9. national political lobby

rm»<• A«r«<%aur cetrfAf

methodological expertise

still

support on introduction
signalling needs
^11 Jilt
public participation
professional skills development
pilot projects
regional political lobby

310

Health Information by
Municipal Public Health Services
Health Information directly
to the public is in the lift.
The last decode, Municipal
Public Health Services
(GGD's) have increasingly
directed their health
information directly to
the public, in addition
to an approach via
intermediaries.
The National Association
of Municipal Public Health
Services tries to actively
support this development.

Mrs. N.E. Warmenhoven

Mrs. N.E. Warmenhoven works for
the National Association of Municipal
Public Health Services in Utrecht,
in several supportive projects.

12

Introduction
Municipal Public Health Services or
GGD's, the Dutch abbreviation, were
founded in the end of the last century.
At first, they were mainly concerned with
taking appropriate measures to prevent
the spreading of infectious diseases.
Later, their tasks were extended as muni
cipalities became responsible for youth
health care, forensic medicine, social
medical advices etcetera; just recently
an Act on Collective Prevention has
been passed stating among other things
that municipalities (and thus, the GGD's)
are responsible for the coordination of

were more or less actively spread among
target-groups, but this is not sufficient.
GGD's started looking for a systematic
approach for giving information to the

public.

Health Information directly
to the public by the GGD
There are essentially two ways for a
GGD to provide the public with direct
information. Firstly, the GGD can provi
de an 'information centre' that can be
consulted by telephone and/or during a
visit. Secondly, the GGD can active1
bring information outside its walls b.
using local media, group-activities, pre
collective prevention in the region.
sentations, expositions etcetera. Infor
Immediately in line with these tasks is the
mation centres ('Gezondheidswijzers')
need to inform and educate the public,
can currently be found at 20% of the
usually to influence their behaviour (e.g.
to take certain hygienic precautions for
Municipal Public Health Services
(GGD's); more GGD's are planning to
examjpie).
, There are essentially two ways
‘
,
startwithinayearorso. All GGD's make
to do this:
via intermediaries (teachers,
' to> use of the second way mentioned to
doctors, welfare workers) and directly
the public. Until the last decade, health inform the public (more or less often).
Ideally, a combination of the two me
education planners working in Municipal
thods is used; a well-equipped infor
Public Health Centres (GGD's) have
mation-desk from where the coordina
focused on the intermediary approach.
tion of outer-directed activities takes pla
Among others, a reason for this was
ce. Although the development of public
efficiency; with just one health educatio
health information by GGD's has defini
nist for 250.000 people it seemed a
tely taken a great step forward, some
good idea to use intermediaries to obtain
problems - or challenges! - remain to
a larger reach. Apart from that, there
be faced.
were and are other good reasons to
Firstly, there is a wide variety in the v'~''s
involve intermediaries in health educa
in which public information is dealt .
tion; GGD's still do. However, the need
It would be much more efficient if all
was felt to pay more attention to the
Municipal Public Health Centres had the
direct information to the public as well.
same basic supply. This would also
There are many reasons for this, such as:
make it possible to refer to the GGD's
• people come to the GGD with ques
(i.e. 'Gezondheidswijzers') during na
tions; it is important to answer these
tional campaigns, which would raise the
systematically, consistently and cor
public awareness of the possibility to
rectly;
obtain information at the GGD.
• the very tasks of the GGD raise even
Secondly, there is the matter of coopera
more questions: regional pollution
tion in the region. As was pointed out in
incidents, the recent (1 992) epidemic
the introduction, other regional organi
of poliomyelitis, the new vaccination
zations also have a task in the area of
for the Hib-type of meningitis, a new
task for the GGD in the allocation of
public health information; patient organizations, hospitals. Home Care and
facilities for the handicapped.
Under Five Clinics, libraries etcetera.
• changes in the financing of health
This does not need to be a problem,, as
care, m<laking it important for people to
long as it is reasonably clear to people
' i care
receive information about health
where to obtain which kind of informofacilities, insurances etcetera.
tion.
It is important that organizations
Of course, there have always been
know about each others activities, so
leaflets on many different subjects that

4

311
that they can refer people properly. It
would be even better if the national
associations of the different organiza
tions came to national standards for
cooperation, so that people all over the
country could count on the library to
minimally supply health information
about certain subjects, the GGD about
other subjects and so on.

• Information and advice about setting
up information centres, regional co
operation, use of local mass-media.
This information and advice is given
to individuals by telephone, and to
groups of workers in meetings and
conferences;
• the Association of GGD's has gathe
red and made an overview of results of
research about the ex
tent to which people
need health informa
tion, and the ways in
which they'll search
for it;
• interesting projects in
the field of public
health information by
GGD's were invento
ried and published, so
that others may bene
fit from their experien
ces;
• a netv/ork is formed
with relevant national
and regional organi
zations, so that many
different initiatives are
attuned to each other
as well as possible.
Relevant developments
are communicated to
GGD's, so that indivi
dual workers need not
actively follow all
trends and develop
ments;
• an attribution was ma
de to the set-up of a
basic information sys
tem by the National
Centre for Health Edu
cation. This informa
tion system is opera
tional now, so that
GGD's can receive a
floppy disk each month
with titles, abstracts
and so on of new health
education
material,
readily disclosed.
For a start, they all
have received a bulk of existing mate
rial, and a database of relevant adresses, on floppy disk as well.
It is evident that this makes a great
difference in the amount of work for
individual GGD's;
• the name 'Gezondheidswijzer' for
Health Information Centres was regis
tered by the Association of Municipal
Public Health Centres, giving us the
opportunity to set minimum quality
standards.

irrForfHalioh

Support for the Public
Health Information task
The Association of Municipal Public
Health Services has supported the deve
lopment of public health information by
GGD'en since 1 988. The goal of these
supportive activities is to increase the
quality and quantity of public health
information by GGD's. To reach this
goal, the following activities - often in
cooperation with other national organi
zations - have been undertaken.

1

Plans for the future
The time seems ripe for a 'great leap
forward' for task to deliver health infor
mation directly to the public by GGD's.
Many possibilities have been explored,
promising starts have been made.
To face up to developments, GGD's will
have to come to a real joint approach
within shortly. The National Association
plans to support this joint approach in
the following way:
• by developing a model for dealing
with questions, so that every GGD has
a 'routing' for dealing with questions
by telephone or from visitors;
• by developing a manual for the trai
ning of volunteers in Health Informa
tion Centres;
• by promoting that all GGD's organise
activities around the same theme (pro
per use of health care facilities) during
one month in 1 994;
• last but not least, by developing a
telephone-device by which people
can dial an 06-number, the same all
over the country, which connects them
with an information desk at the GGD
in their own region. In this way, they
can receive general information as
well as information about facilities in
the region. Naturally the results of
other projects will be used, like the
basic information system by the Natio
nal Centre for Health Education, and
regional projects. Because this is an
ambitious plan, a feasibility-study will
be carried out first.
In this way, together with GGD's and
other actors in the field, we hope to
come to a covering network of regional
health information of high quality.
Judging by the enthusiasm and interest
of all concerned, it seems an obtainable

goal.
More information can be obtained
at the Association of Municipal
Public Health Services
Postbox 85.301
3508 AH UTRECHT
Telephonenumber: 030 - 523004

13

312

Dear Customers
It has dawned on
Municipal Public
Health Services that
satisfied customers are

very important to keep
an organization going.
Nevertheless, many
conditions for a
customer-directed
policy are still lacking.
Health Education officers

at many Municipal Health
..
Services are usually most
active in this respect.

Mrs. N. van Tankeren

t the First National Conference on
Quality of Health Education in
/ \June 1 992, 'paying more attention
to Health Education-customers' was one
of the important items to improve the
quality of Health Education (the reader
is also referred to the article of A.
Veldhuizen 'Struggling for Quality').
More attention for the customers in
Health Education-programmes impro
ves the involvement of the customers.
The Health Education programmes can
be better adapted to the problems that
people have nowadays and find solutions for these problems which can help
the customers in their daily life.
The Health Education product is made to
A

measure and directly applicable. By
letting customers participate in the set
ting up and execution of Health Educa
tion-activities, they will be more willing
to help thinking about the different sub
jects, to search for solutions themselves
and where necessary to change their
attitude.

Continued Existence
Customer-oriented policy also serves
another goal. Satisfied customers are
important for the existence of an organi
zation. Customer-oriented organizations
are consulted more often and in a more
effective way. Lack of attention for the
customer means that sooner or later the
customer will criticize the organization,
and criticism often sounds louder than
praise. When the population is unsatis
fied about its Municipal Public Health
Service the Municipalities that mainly
finance the Service will look at the
Health Service first when they have to
economize.
Municipalities are very susceptible to the
opinion of their population. A Municipal
Public Health Service that the population
doesn't care for or that Municipalities
cannot go to for advice aren't very
attractive to them. Sooner or later this
may become a danger for the very exis
tence of the Service.

Customer-directed policy
Mrs. N. van Tankeren is head of
the Health Education department
of the Municipal Public Health
Service Zuid-Oost-Utrecht and
co-editor of GGD-News.

14

A Health Service that wants to pay more
attention to its customers often thinks in
the first place about an open and friendly
reception. But mere customer-friendliness
isn't the same as a customer-directed
policy. A visitor who has skipped work
during lunchbreak for a vaccination and

HEALTHKMH3ATION SFECIAL

who is told in an oh so friendly way that
the consulting-hour is over, isn't satisfied
at all! Giving visitors a good reception is
important but to really satisfy customers
an organization has to pay attention to
his needs and the way he gets what he
wants in the end.
A customer-directed attitude therefore
means that the organization takes the
needs, wishes and possibilities of its users
into account and offers a policy that
satisfies the customers because of the
high quality and applicability.

Get to know the customer
Unfortunately
customer-directedness
does not come about all by itself just
because all employees have the intention
to pay more attention to the customers in
the future. To work in a customer-directed
way we will first have to get to know the
customers better. This asks for specific
expertise in the field of Public Relations.
To set up activities together with the
target-group often costs a lot of extra
time. A customer-directedness policy can
not be made just like that, it may give rise
to a lot of discussion and can raise
resistance within the organization.

Clashing interests
Health Service employees really want to
deliver high quality work which is one
more reason to involve customers. Indeed
the users of the Health Service also want
high-quality products but on the other
hand they want direct action and direct
results. More than once they have wish
that do not concern the most importani
health problems. This is where a conflict
of interest may arise: the wishes of the
professional based on expertise and limi
ted financial possibilities, and those of
your clients.
Imagine the following dilemma's:
• You know that there are health-losses as
a result of elderly people who have
falling-accidents in and around their
own homes.
You think that this is an important issue
to educate and inform people about
and to arrange safety measures. The
elderly people in your township don't
see this problem. They are not falling in
their own home! They would rather see
something change in the streets: they're
afraid of burglary, mugging and hand
bag robbing (which do not happen that
often at all).

313
• A social-medical check-up of pupils
once every two years is enough and
you could even drop this frequence in
a responsible way but parents would
rather want such a check-up every
year.
• You are convinced that the factory in
the neighbourhood doesn't have inju
rious health consequences for the peo
ple living there. They want a thorough
investigation.
• You cannot find social or medical
reasons for your patient to be eligible
for certain subsidies to make adjust
ments in his home. He expects you to
search him over and over again until
you actually find something that can
help him in this case.
• The Municipality wants a project on
gambling-addiction before the upco
ming elections. For a political view
point this is a well chosen subject.
Before you can set up this project in a
responsible way you first want to do a
thorough investigation about the po
pulation concerned, background and
the kind of problems that exist around
this subject. The Municipality wants a
large and attractive educational pro
ject as soon as possible.
As you can see it isn't simple at all to
consider all the needs and wishes of the
customer and where to draw the final
line.

Customer-directed Policy:
fast results
• The organization of your work
Investigate waiting-times for example
and compare those results to the ave
rage waiting-time which you and your
customers find acceptable. You could
also do a test on how fast the telephone
gets picked up, how long people are
put on hold, whether one is actually
connected to the person asked for or
how soon a return-call is made. An
important item to investigate as well is
how easy it is to make an appointment
on a day and at a time that suits the
customer the best.

needs of your clients, and how you can
involve them as much as possible in
your work, isn't easy at all to answer.
Intensify the contacts with your targetgroups, have an open and interested
ear for what goes on and take this into
account as much as possible in your
work. This is already a first step you
could take.

Employee-directed policy:
a prerequisite for succes
To succeed in creating a customer-direc
ted organization, which delivers high
quality products and which is apprecia
ted by the population and Municipalities

M\

Customer-friendliness: fast results
Still there are certain aspects in the
service in which all Health Services
could and should make improvements
on a short term.
• The reception
• Dealing with complaints
you have to earn the willingness and
Give the customer the feeling that he is
Do not consider complaints as
cz anGr,
dedication of all of your employees! To
welcome. Receive him in a clean, tidy
noying. They usually give you a clear
be sure that employees are friendly and
and tastefully furnished building.
view on what occupies your
tar?fL
helpful, proud of their organization and
Offer him information which he finds
group. Make sure there's a clear and
willing to show that to the outside world,
interesting and perhaps even coffee or
fast procedure for complaints. Ack
you need an employee-aimed organiza
tea.
nowledge understanding for the point
tional policy.
• The personal treatment
to
Sh°W =St in
Others upbringing
------------- jpbringing
Approach your customers politely, lis
maand ideas, show appraisal, give posititen carefully and with interest to what
an^
Ve ^ee<^x,c^/ show openness and clearthey have to say and want, be willing to
write a complaint. Listen carefully
■ ■ xto->
ness, and make room for democratic
give them the service they ask for. Keep
what the complainer really has in
£
.
•
----/
* in
resolutions.
yourself to the appointments you make.
mind, f*
r ‘
‘___
• Presentation of material
ask questions and do not try to justify
petition between the different sections in
See to it that letters, leaflets, brochures
yourself too much. This is something a
the building which lowers the quality of
and other material looks attractive and
complainer doesn't want to hear at
work.
that there are no spelling-mistakes in
that stage anyway. In the end, be clear
uvvicwi
Good working-conditions, an open ear
them.
about what you are g a ™O!n? tO
f°r -the Wishes of
emPk>yees and
• Clearness
do about the complaint.
mt A complainer
willingness to adapt to them are all very
Information must be clear and easily
who is received in this way has lost
important aspects.
understandable, whether it concerns
most of his discomfort already.
An employee-directed Municipal Public
health information, or the results of
• An open ear
Health Service is a condition to reach
your work and the backgrounds of
The question of how much you want to
customer-directed Health Education for
your decisions.
(or have to) adapt to the wishes and
sure!

I

15

x

. ''V

>5.

314

Living Together
Regional networking to enhance school policy
on sexual education in secondary schools
The programme

K structural approach to both the
ZA instruction on AIDS and other STD's
/ \ (Sexually Transmittable Diseases)
and
to the
prevention
for Health Education
demand
a policy
in secof sexual assault
secondary schools.
(section Education)
A policy that exceeds> mere teaching,
integrates two
and integrates instruction with theJ care
for
pupils and a school environmentthat
projects. Both are
is beneficial to their health. To support
directed towards
this, a coherent approach is necessary.
supporting regions in
Regional networking is a prerequisite to
The Netherlands in
offer coherent support using different
skills, disciplines and institutions.
introducing a school
The
programme 'Living Together' thereby
policy on sexual
puts into effect governmental decentrali.•
r
i.
I
education in
zation of policy
,
, andJ means.
secondary schools. li also links up closely with developments
At issue are the
in education:
ec^ucahon: new subjects are being
added to the curriculum ('basic educa
project 'Regional support
tion') needing adequate interpretation
sexual education' and
of teaching goals; more attention is paid
the project 'Prevention
to the care of pupils, their skills in
decision-making
and their independenof sexual assault'.
ce. In the programme Living Together,
the National Centre for Health Educa
tion offers regional coordinators of Municipal Public Health Services (GGD's)’
personal guidance in networking and
Jo Reinders, developing
a coherent support for the
Aad Doorduijn schools. The programme is based on a
pilot-project of the Health Education
Department of the GGD in Utrecht that
proved to be successful, both at schools
and in the region.
This article describes the reason for the
programme and the approach to regional networking in practice.

'Living Together' of
the National Centre

The necessity of a school policy

Jo Reinders is programme-director
of Living Together,
Aad Doorduijn is region-consultant
/ith the National Centre for Health
Education, section Education.

16

Over ninety per cent of secondary
schools pay attention to AIDS-education
in one way or another. Often it is more
or less isolated attention. Incorporating
AIDS-education in education on STD's in
general, and the two of them in sexual
education, often fails to come about.
Besides, almost half of the schools lack a
structural approach. AIDS-education is
confined to the upper grades, with too
much focus on instruction. However,
according to research, over thirty per
cent of adolescents from the first and
second grades have had sexual experience.

For the prevention of STD's, adolescents
need to be able to communicate values;
they need an open attitude and commu
nicative skills (Vogels a.o., 1 990, Peters

a.o., 1991).
For a more structural approach to AIDSeducation teachers lack the support of
colleagues and school management.
These conclusions resulted from research
among six hundred secondary schools
and eleven hundred teachers (Paulussen

a.o., 1992).
__
.... prevention of sexual
With respect
to the
assault,, not only
/ the Ministry
/ of Edilucation and Sciences insists upon a school
.
. . .
policy (Emancipation Memo, 1992),
but there is also an Act on Working
Conditions that stipulates that (preventi
ve) measures are taken to deal with
sexual intimidation.
Institutions, such as schools, have to
w
make arrangements
for (public) welfare
at the workpla<ice. To be able to do this,
the Emancipation Memo of the Ministry
of Education and Sciences urges schools
to inform after possibilities for support by
regional organizations for health and
welfare.
A school policy that coordinates AIDSeducation, prevention of STD's and sex
ual education in general is therefore a
new challenge to secondary schools.
Together with this, personal advice and
training in the selection and use of
teaching materials and the reception of
pupils with relational or sexual problei»ms
are essential to better sexual education
and a more structural approach. These
are the reasons to focus on regional
(nearby) school guidance and school
policyr on sexual education.

Basic education
From August 1993, basic education will
be introduced into the first grades of
secondary education. Several central
goals for the subjects biology, physical
education and for the recently introduced health-class oblige schools to pay
more attention to sexual education,
emancipation and prevention of sexual
assault. Besides, schools are expected
to emphasize on care for pupils and to
prepare them for making their own

!

i

j

315
decisions on health, relationships and
sexuality. With a school policy on sexual
education and an integration of different
aspects of sexuality into the curriculum,
the lessons and the care given by schools
will gain in quality.

School policy
The programme Living Together has the
integration of the following three themes
in sexual education as a starting point:
• AIDS-education and education
on STD's;
• prevention of sexual assault;
• emancipation of homosexuals.

The Health Education officer and social
nurses of the Municipal Public Health
Services and counsellors of institutions
for sexual education and assistance can
advise the teachers on their lessons.
Mentors and intermediaries at school
can be assisted by the Youth Health
Department of the Municipal Public
Health Service, institutions for mental
health and social work. As for specific
skills of teachers and school manage
ment and the enhancement of a healthy
school environment, National Educa
tion Centres and Universities play a
prominent part as well. Cooperation of
different, regional institutions and disci
plines is therefore indispensable to a
school policy.
The schools' needs of support with res
pect to sexual education is covered
coherently. This prevents haphazard po
licy of supportive organizations and
limited effects due to dispersion of ef
forts. Also, schools will be less easily
frustrated by a surplus of all kinds of
support and advice, or by getting lost in
a forest of institutions without cross
reference.
The programme Living Together intends
to promote regional cooperation and a
coherent support by means of networ
king. For every region a regional coordi
nator will be appointed. Thus, Living
Together links up with the governmental
policy, i.e., to integrate Aids education
into education on STD's and both of them
into sexual education (Advancement Me
mo, 1992). Regional support also fits
into the governmental aim at decentrali
zation of policy and means.

In fact, breaking the barrier between
sexes runs through these themes like a
continuous thread. A broad, life-style
approach and incorporating the hazards
of sexuality into a jpositive approach
towards sexuality in general are essen
tial in this matter. The exchange of
personal norms and values and learning
to apply knowledge and skills in the
private environment are the focus of this
approach. Consequently, teachers will
sooner be confronted with personal pro
blems of pupils such as |problems
___ with
relationships, sexual intimidation and
abuse and doubts about their sexual
preferences.
Living Together' is not just directed at
lessons (instruction). The reception and
guidance of pupils also need attention
through expert pupil guidance, confi
dential persons and narrow contacts
with services outside school, preferably
via the school medical officer.
Moreover, for an open atmosphere in
the classroom an open school environ
ment is necessary; an environment in
Personal consultation
which there is room for pleasant social
Consultants from the National Centre for
intercourse, exemplary behaviour of
Health Education are supporting fifteen
teachers and other staff-members and
regional networks between October
rules that discourage sexism and discri
1992 and January 1995 through their
mination. Also, an environment that pro
regional coordinator. Per region it takes
vides for correct information in the school
one year of support, threecjuarters of a
library, health products (sanitary towels
workday a week.
as well as condoms) and that tunes in to
The regional coordinator is bound by
the pupil's domestic situation and the
contract to spend one workday a week
involvement of parents
or
specifically
i
- guardians.
o------------i
-------- '—7 on Living Together.
ucation, care and school environment The coordinator is responsible for the
are t e three cornerstones of a school joining of efforts of regional organizepolicy on sexual education.
tions and for making contacts with
.
schools.
schools. The
The fifteen
fifteen regions
regions have
have been
been
n ersec oral cooperation
selected
selectedfrom
fromaatotal
totalof
ofthirtythree
thirtythreeappliappli
as prerequisite
cations.
cations. Selection
Selection criteria
criteria were
were geogeo
upporting schools in making school graphical spreading over the Nether
Nether-
po icy on sexual education requires a lands
lands and
and sofar
sofar limited
limited cooperation
cooperation inin
continuous, personal contact and the the
region.
the region.
pplication
With the
the help
help of
ofaa workbook,
workbook, the
the workwork
app
ication of
or different
dirferent expertises
expertises with
with With
respect to education, care and school book
book Working
Working Together
Togetheron
on Living
Living TogeToge
e- vironment.
th
Gr consultant'
ther,
consultants nffor
offer tko
the rani^nnl
regional co-

ordinators a grip on networking and on
the development of a joint offer in seven
potential areas of intervention:
1. materials and methods;
2. training and refresher courses;
3. supply of information;
4. policy development;
5. network development;
6. research;
7. documentation.
The aim is to have networks in fifteen
regions at the end of 1994 that work
according to a lasting policy-plan and
offering coherent support that fits the
requirements of the schools. In addition,
the workbook shall be completed with
the results of the fifteen regions so that it
will be a practical instrument for freshly
starting regions.
In practice, the coordination of an inter
sectoral network is the concern of the
Health Education officer. Choosing a
Health Education officer has an additio
nal advantage because school policy on
sexual education can be extended to
other themes and, eventually, into an
integrated school health policy.
Besides sexual education the network
can, for instance, supporta school policy
on nutrition, stimulantsand safety. Being
responsible for the collective prevention
in public health, only the Municipal
Public Health Service can actually cover
the extent of such an integrated policy.
Pragmatic considerations also argue for
the choice of the Municipal Public
Health Service as coordinating organi
zation. The Health Service has, for in
stance, the means to try to convince
municipalities to (partially) spend AIDSfunds (formally controlled by the natio
nal government and now decentralised
to the Municipalities) on the project
Living Together.

Networking in practice
In practice, all relevant regional organi
zations that have to do with education
are involved in networking. The process
of network development is characterized
by the principle of exchange: through a
cost-effectanalysistheinterlocutorsdecide whether they have enough to offer
each other to start a functional, purpose
ful network. The flexible approach to
support 'made to measure' requires a
planned approach with definite ultimate
goals, phasing and workplan. First of all
it is essential that a project group is
formed at management level. Existing
networks may feature as network of the
project group Living Together, e.g., existing networks on sexual assault, networks of the Dutch Association for Youth

17

316
Health or networks in
zial-cultural work. The
Bergen op Zoom Municipal
Public Health Service, for
example, is now approa
ching the existing workinggroup 'pupil guidance' to
see if the group wants to
play a part in the Living
Together project 'School
policy on sexual educa
tion'.
Dependent on the tasks that
have been agreed upon to
gether with the project
group, working-groups will
be formed on an executive
level, e.g., on AIDS-education and education on STD's,
prevention of sexual assault,
emancipation of homosexumaterials.
In these working-groups you
will always find representa
tives of education.
In practice, working-groups
on sexual education usually
function on a school level
and working-groups on pre
vention of sexual assault on
an inter-school level.

Approaching
the schools

VRIJEN... EN JIJ

hurt

B
IFW. I

When a regional network
wants to contact schools, it
is important to go along
with the activities of a school
and its teachers as accura
tely as possible.
This enables cooperators
f ti public health and edu

cation to create supportive
activities made to measure.
This demands a personal
approach with intensive
(verbal) contacts with a re
latively small number of
schools.
Accordingly, subsequent to
consultation with headmasters, the Health Education
officer and a youth doctor of the Munici
pal Public Health Service in Amstelveen
are carrying out conversations with
school managements and teachers to
materialize the apparent need for a
project Living Together.
Firstly, the coordinator clarifies the com
mon premises on a school health policy
centred upon the themes of Living Toge0Thereupon the coordinator outlines
1. . joint contributions the network could
make in order to realize the central

18

AIDS
goals of basic education and the care
for pupils. The wishes of the schools are
vital to this.
Specific skills of the separate network
organizations and network officials can
be discussed. Hence, it is essential that
in the school broad support is realized
for the innovations.
In order to reach consensus and to work
on the innovation systematically, it is
crucial to appoint a schoolcontact and
arrange an internal working-group.

Those involved can frame an 'activity
plan for school policy on sexual educa
tion' in consultation and cooperation
with the supportive network.
Thus, the start of the implementation of a
school policy on sexual education in
school has become a fact; the prerequi
site for an optimum guidance of adoles
cents in a healthy sexual growth and
development.

i

317

Peer education on AIDS
Adolescents run the risk

Cooperation

of contracting AIDS and
was essential to this project to look for
Other STD's (Sexually
cooPerators other than teaching organi• ■
zations. During the orientation phase
Transmittable Diseases).
we contacted several organizations that
They are still in the work with children who do not attend
stage of experimenting,
school.
they are insecure about During these discussions it became evi
dent- that youth work and street-corner
expressing their own wishes
work saw possibilities to incorporate
and expectations, and they aids education in their activities.
are not experienced in Therefore, we have cooperated with
these organizations in the rest of our
'safe-sex' behaviour yet.
activities;
we organized courses for youth
Young people with little
workers, the juvenile police squad and
or no schooling are even street corner workers. Safe sex parties
more at risk. On average,
were organized, and a play about safe
they start having sex at a sex and AIDS was performed by a
Moroccan dramatic club.

younger age, education in
class situations is less
accessible to them and
they have more difficulty
communicating with their
partner. Those were the
reasons )why the Health
Education (GVO) Departmentf
of the Municipal Public
Health Service (GGD) in
Utrecht introduced a
project for this group
two years ago.

Mrs. I. van de Vegte

Mrs. /. van de Vegte is Health
Education Officer in the GVO
(Health Education) Department
of the GGD Utrecht.

Peer-education
In order to reach those adolescents who
not 9° to y°ut^ centres, a peer
education project has been developed
in cooperation with Street-corner Work
Utrecht (STRAND).
With peer-education, information is given by people from the target group
itself. Peer stands for 'equal'
and 'mate'.
,
_
taboo-subjects, such
as AIDS, it is important
to associate
with
.
------- -----the social climate of the target-group.
^his can be realized by allowing young
, —J
people from this target-group to give the
jnformatjon themselves^ In this way you
information themselves. In this way you
will also gain more insight into the ideas,
wishes and life-style of the target-group.
We started from an experimental situa
situa-
tion in which several young contacts of
the streetcorner workers were trained to
act as instructors.
This experiment received some financial
assistance from the AIDS-fund. This sub
sidy was spent to employ three additio
nal streetcorner workers (five months,
three hours a week, per worker) and for
the working hours of the adolescents
(four months, four hours a week.
week, per
adolescent).
STRAND (Streetcorner Work Utrecht)
has taken on six adolescents for this
project. Two Moroccan boys, one girl
from Surinam and three Dutch girls.
Their average age was about 21.
These young men and women have been
contracted for the duration of the pro
ject, so it was an actual job for them.
This choice has been made for a number
of reasons.

Firstly, it guaranteed that the information
would actually be given for several
months on end. Secondly, the money
would motivate the adolescents to join
in. And last but not least: they were thus
given enough status to take the initiative
in discussing AIDS and safe-sex with
their friends and acquaintances. They
do it because it is their job and therefore
it is more readily accepted.
As it was, they were anxious about the
following response: 'Why do you begin
about AIDS? You will probably have it
yourself!'
A short-term training has been organi
zed in which basic skills and information
on AIDS and safe-sex are communica
ted. These initial meetings have been
kept short in order to keep these adoles
cents, generally with negative school
experiences, interested. During these
meetings it became clear that they were
very motivated and that they thought the
subject to be very important. There is a
sensation of sex and death around AIDS
that appeals to young people. They
wanted to see an AIDS-patient.
Also, stories were told about programs
on television on AIDS that they had seen,
They were very sympathetic, especially
towards those people who had been
infected 'through no fault of their own',
e.g., children, via bloodbank etcetera,
After that they went out, into the streets,
with leaflets, posters, stickers and so
called 'free tickets' containing condoms
('to free' means 'to make love' in Dutch).
Once every fortnight a follow-up course
was organized; on STD's, homosexuali
ty, what it is like to have AIDS, and
educative skills. The streetcorner wor
kers met weekly for a supervisional talk
in which they discussed their activities:
where and how many boys and girls did
they talk to, their reactions and the
workers' own experiences.

The conclusions
The adolescents themselves were very
enthusiastic. Weekly, about a hundred
to a hundred and fifty boys and girls

have been dealt with. Places where they
particularly operated include: coffee
shops, gambling-halls, cafe's, disco's,
house-parties and vocational guidance
classes. Furthermore, the girls often held
individual conversations with people at
home, general practitioners, prostitutes
and so on.

19

318
Most reactions of other adolescents to the
materials and the stories were positive.
The condoms were taken along eagerly.
In the first few weeks the emphasis was on
distributing educational materials. After
a time, more and more discussions on
safe-sex and the use of condoms follow
ed. Some adolescents stated that, at
times, it was hard for them to be taken
seriously. Or as one of them put it: 'I am
always jesting, they think I am making a
joke now, too.'
The Moroccan boys met with negative
reactions, particularly from older Moroc
cans. They were reproached for being
manipulated by the CIA and for working
for the West, 'AIDS does not occur
among Muslims, does it?'
From reactions of adolescents it became
clear that the use of condoms is not
accepted, especially not within rela
tionships. Nevertheless, condoms are
being used for casual contacts. Besides,
the price of condoms appears to be an
impediment. Another evident obstacle
was that in order to use the condom
properly, one should turn on the light
during love-making.
The street-corner workers are very opti
mistic. They are surprised at the enthu
siasm of the adolescents and at the fact
that they kept their appointments. The
latter is probably related to the fact that
the adolescents are paid for the job.
Still, the importance of the subject defini
tely contributes to their enthusiasm.
A positive side-effect is that a number of
coffee-shops intend to install condom
machines. The adolescents who have

taken part in the activities receive a
certificate. This induced two of them to
enroll in a vocational training.
STRAND has expressed the wish to pro
ceed with this experiment. They mean to
start a new working-group every six
months with adolescents from again
other subcultures who, in turn, know
other young people. Especially boys
and girls between fourteen and sixteen
years old should be reached more often.
Peer-education is not yet a much used
method in the Netherlands, least of all
where "Fringe group' adolescents are
concerned. The experiences in Utrecht

have shown that this method can be very
efficacious for them, too.
You can buy the work-book for youth
work: On Aids & Sex (Dfl. 20,- postage
not included) as well as an extensive
report on the project (Dfl. 10,- postage
not included), both in Dutch, at
GVO-Utrecht, Wittevrouwensingel 74,
3572 CD Utrecht, The Netherlands,

tel. 030 - 732599.

20

3rd European Conference of the
International Union for Health Education (IUHE)
HEALTH EDUCATION & MASS MEDIA
How to communicate effectively
24-26 May 1993
RAI Congress Centre, Amsterdam
Central aim at the conference is the relationship between health education, mass
media and effectiveness. Plenary sessions will include keynote speeches and

panel discussions, both allowing for audience reaction.

Topics to be featured are:
• L'ethique de I'education pour la sante par la communication de mass
J.F. Lacronique, Director Comite fran<;ais d'Education pour la Sante

• The present and future of European campaigns
Dr. E. Ziglio, WHO Regional Office for Europe, Health Promotion Unit
• New multimedia and health education
Prof. dr. J.P. Schade, Educational Media Institute, Utrecht University,

The Netherlands
• Evaluating Mass Media Health Promotion: Prevention is Better than Cure
Prof. dr. GJ. Kok, University of Limburg, The Netherlands
• Behavioral journalism: The Audience Is The Message
Dr. A.F. MacAlister, Center for Health Promotion, University of Texas, USA
• The future of the use of mass media in health promotion
Prof. J. Catford, Health Promotion Wales, United Kingdom
• Interdisciplinary cooperation in producing various types of television

programmes
Ms. M. Bouman, Netherlands Hearth Foundation
Parallel sessions will cover a wide variety of themes and subject ar®a^The sessions will deal with the keynote themes and other topics, including:

- the effectiveness of Aids and sex education
- the effectiveness of smoking cessation education
- methods of effectiveness research in mass media education
- methods of mass media education
- the role of journalism in conveying of health messages
- the integration of national and local activities in education concerning the use of
alcohol, smoking, dental health care, prevention of sport injuries and cancer
education
- interdisciplinary cooperation in the production of soap operas, game
programmes, talkshows and health programmes on radio and television

- educational broadcasting on television

- school television
In two different workshops participants will be offered the opporkmity to exchange
experiences and ideas with communication experts on the possibilities and limitations
when using multi media in health education.
,
The above subjects will also be highlighted in poster presentations, the Media market,
the Video show and the presentation of the Health Award. Fiesta Amsterdam
the
congress party on May 25 - will also reflect the conference theme and celebrate its

European dimension, with a touch of Dutch!
.
The conference is intended for people with a professional involvement in health
education and the mass media. The programme is designed for health educators who
work at national, regional and local levels in a variety of settings as well as tor
policy-makers, researchers and professionals involved in the mass media like |oumolists, TV-producers, public relations staff, communication specialists and advertising

On-siteO^7stration for lUHE-members is Dfl. 1.000, norwnembers pay Dfl. 1.050.

SrXSer'iXrX^p^ase contact Marianne Smit, Dutch Centre for .Health Promotion
and Health Education, P.O. Box 5104, 3502 JC Utrecht, The Netherlands
Tel. 31 30 910244-Fax. 31 30 964082.

4

319
DEBATE

!

THERE have been a number of articles defining health piecemeal as neaim education touching aspects of
promotion and describing the variety of activities all approaches to a variety of health problems in a less
undertaken m its name’- 2345 Each of these papers than totallv co-ordinated way
Surely what we should be aiming for is a co
refers, either directly or indirectly to a definition drawn
ordinated
service managed by a district health
up by a working party of SE Thames health education
officers, and the members of the Unit for the Study of promotion officer/adviser/specialist. who has the
Health Policy, who met during 1982 to consider the ability to understand the work involved in both the
fields of education and social policy Within the
place of health promotion after reorganisation6
At this time we defined health promotion thus service one would have two teams of officers/
The terms health promotion and health education advisers, one m health promotion and one m health
are not interchangeable. Health promotion covers all education These would be specialists in their own
aspects of those activities that seek to improve the right, and equals Their background and training
health status of individuals and communities It would reflect their roles in social policy change and
therefore includes both health education and all m 'education They could work m pairs on specific
attempts to produce environmental and legislative: projects the differences m their outlook and approach
change conducive to good health Put another way. beino of mutual benefit. Within 'education would be
health promotion is concerned with making healthier included mass media activities, naming, and commu
nity education the latter being not only for 'agenda
choices easier choices. "
The paper then went on to outline some of the ways setting' purposes but also to enable decision making
m which health promotion activities would be carried and community participation in change. These teams
out. and suggested that as well as health education could be supported by people with specific skills,
officers there should be a new'-'breed of officer, the perhaps in research, community development or
health promotion officer. The health promotion officer publicity as required
Departments staffed in this manner would certainly
was described as a "new specialist who would
be
in a better position to get on with the job of health
concentrate on the social, economic and other barriers
promotion
in its widest sense, and perhaps then we d
to health", while the health education officer had
all
have
a
better
idea of what the term could mean
"expertise in the transmission of health information"
Over the last few years there has been an increasing
recognition of the importance of external influences
upon
health and constraints on behaviour change. References
____
J A jmversal definition of health promotion The
Education about health directed solely at individual 1 French
Health Services 26th August 1983
change was dismissed as victim-blaming, and 'tradi 2 Adams L Health Education/Health Promotion definitions/
aims/issues London Health Education CounaL 1983
tional' health education has been much maligned.
Tones K Education and health promotion new direction
Possibly we have now reached a position where we 3 Journalofthe Institute of Health Educauon 1984. 21. 121
can recognise the benefits of different approaches to 4 Seymour H Health education versus health ProT°no%84
practitioners view Health Educauon Journal 1984.
improving health, and organise multi-faceted pro
grammes without fear of losing the allegiance of 5 CatkDrd IN utoeam D Towards a definition of he^p^.uc1ag^n
and health promotion Health Educauon Journa
various factions within the profession.
Dennis^J et al Health promotion m the reorganised NHS The^
However, these developments towards the practice
of a wider view of health promotion have occurred in 6 Health Services 26th November 1982
patchy and relatively unplanned ways. Job and
service titles have changed, perhaps reflecting more
the attitudes of the post-holders than the reality of the
Officer for
work that can be undertaken. Without adequate •Dr Viv Speller is District Health Education
staffing 'health promotion' activities are likely to be as Wandsworth Health Authonty
96

4

SUMMARY

“““

SSS, IS',™"'

a,. V.,,..

m toe yXs 184o£ 1890,“who ^p^ to^wto^ toetolto of toe^ata^s

£=«

involved in public health research and worked for the improvement of public
hygiene and for the introduction of preventive medical legislation. Furthermore
tfiey became active in political and social organizations and acceded into
government bodies. In this study these doctors will be referred to as sanitary
rerormers or hygienists.
7
One of the theses to be developed in this book is that the hygienists played an
essential part in replacing the old medical notions of the Ancien Regime by a
new medical paradigm. This shift is placed in the context of the socio-political
developments which took place after 1848: the transition from the traditional
class-ndden society to a modem, liberal and unified state. Municipal autonomy
was to play an essential part in this modem state, created in 1848 by the
Minister of Internal Affairs, J.R. Thorbecke. It was the middle classes in
particular, including doctors and other members of the liberal professions who
supported this development. They wished to acquire an important place in
society, till then dominated by the aristocracy.
General dissatisfaction amongst doctors with their position in society and with
the poor state of the population’s health led to the formation of the Dutch
Society for the promotion of Medicine (NMG) in 1849. The hygienist movement
rose in parallel to this. The 1848 revolution liberated new energy amongst the
middle-classes. In Germany doctors sided with the revolution in the conviction
that corrupt and decayed regimes were responsible for the poor state of the
nation’s health. Their attitude had a great impact on the Dutch medical professi
on.
During the same period, all of Europe was visited by a cholera epidemic. The
1832 epidemic, which was countered by quarantine measures and philanthropic
care, had had a disastrous outcome. This stimulated many doctors to approach
the nation’s health in a new way, in which public health care alone was stressed.
The hygienists were not just ready for new medical ideas; they were also
convinced that only political reform along liberal-democratic lines could create
the necessary conditions for hygienic reform. Political and medical reform were
inseparable.
Politically the hygienists were on the side of the doctrinaire liberals and their
leader Thorbecke. Both the liberals and the hygienists stressed the importance
of municipal autonomy. Thorbecke considered it of the utmost importance for
the vitality of society that the state did not impose all kinds of regulations from
above. The hygienists also believed that in the first instance a local, that is
municipal, health policy should be developed. Central government would
intervene only if local policy failed to improve public health.
This attitude towards the nation’s health radically contradicted the technocra
tic-statist model, propagated by GJ. Mulder, professor at the University of
343

He advocated
and
professors. His thoughts owedgovernment
much t
however, his political
-- concept failed to attract

During ihl "848 revolutio^^me of°hem
enough had
to .COO|T“e ClOSe‘y With Thort>«*esome of them had
and the emancipation of the working dass co^M
'hat °nly higher wa8es
‘
“,e working
class could
After t«sn
1850,
the hygienists
embraced
th^ l"'prove the nation's health,
50, however,
however, the
hygienists embraced
ne of Max von Pettenkofer professor rrfhv* m°re conservative ’Bodentheo»tl pollution as the main c^of ep demies'ami
COnsidere<,
measures mtended to combat this pollution
3 5601:5 °f technical

Belgium mathematich^H^d"statisrici^LA51; 0°°^ the'r inspiration
from the
was that under normal conditions social and hSl*6 6 et|' .Quetc,el’s Orting point
cnminality suicide, intellectual capacitms ^d^'mnn n SUCh 35 h^V'ength,
amongst the people in a 'normal distribu on' Van imOrtallt>’' were d.stnbuted
to have a cause, which could be removed hv
"'T.
3 nega,ivc sense had
According to Quetelet statk.Vc
by 1)0,11,031 measu^s.
progress. Based on these thoughts
eXpedienl in serving social
developed the so-called b.ometer H calc"
^°rmer W"liam Farr
17 per thousand. Higher municipal death ™
Physiological’ death-rate of
m the field of public health. AccordinP tn^P Were dUC t0 P001- P°licymaking
must change their policy. Following in the foot^’
CaSe local ai,th°rities
published the first Dutch atlas°™m<Xy m l865. °
"'
Du'Ch hygienis,s

KJ

O

A new reality
The statistical publications of the hygienists did nm
not
present an objective
description of reality. Statistics created^
r
? just
J
through statistics the hygienists placed all^iv'ilian^ W'lh,n th'S realily' First,y’
all civilians
hygienist-statistician a d^th always carried
the «
?Ual leVeL For the
death always carried the
cholera of an upper-class civilian nr
□
C
53016
•
wei
BhtThe death from
or a p'-- equally. How the different classes shared i^this^rtl0Creased ,he dea,h rate
shared
in
this
when the biometer was employed.
mortality, was of no relevance
Secondly, the hygienists considered the
mortality
rate in the
the i-----same way as the
value of a thermometer, expressing the cons^uXes
expressing the consequences of pathogenic, local
environmental and life conditions • 1'
'
"
Mortality and morbidity
represented on
maps, together with geographic data and details" of^, were
Edition?
-------- Diseased
a city could be recognized at
rates reflected
Through statistics the hygienists also created a new political order

0

7

In

J)
medicine and

344

(n

ses were the expression of poor management of the environment, a result of
lack of civilization and faulty policy-making. Thus, diseases were symptoms of
poor leadership. This statistically demonstrated connection between disease and
policy placed disease and individuals in a new relationship, for, in many cases
the connection implied that civilians died through no fault of their own. Hence
forth, civilians dying of an epidemic disease should be considered as victims of
those obstructing ’progress’. According to the hygienists, precisely this reality
created by statistics, had to be the central issue in the debate on the nation’s
health.

The power of statistics

Statistics became the most important research tool, because statistics, unlike
existing methods of research, offered a clear perspective on a programme to
improve the nation s health. Statistics transformed epidemiology into a practical
science with great social benefit.
According to the hygienists, the dragging discussion on the question as to
whether cholera and other diseases were contagious was not relevant. This
discussion had produced very few results in the preceding period. Thoughts
about the nature and the life cycle of infectious matter and about the pathophy
siological process in the human body had remained merely theoretical construc
tions. In other words, around 1850 scientific research had become deadlocked.
In opposition to this discussion, the hygienists put forward ’objective’ measure
ments and empirical research. Statistics met their need to frame an inductive
science of epidemics, just as the natural sciences fulfilled their wish to give
pathology and therapy an inductive basis. The microscope and the pathologicalanatomical atlas were the most important expedients in clinical medicine,
statistics and topography in epidemiology. Consequently, statistics created the
possibility of arguing ’scientifically’ at a time when the ultimate causes of
epidemics were shrouded in mystery. Without seeking out hidden causes (for
example, the contagion), one could study correlations between a number of
aspects of the ’hygiena publica’ and the appearence of common diseases. With
this, epidemiology was transformed into a science which directed the social and
political activity of both doctors and politicians.
Within ten years statistics came to dominate epidemiology. The success of
statistics was based on three properties: the increase in scale in the number of
data, standardization, and the facilitation of the process of dissiminating data in
different directions.
Firstly, after 1850 statistical research was done by a nationally coordinated
network of doctors, capable, after a short time, of publishing surveys of mortality
and of various diseases for the country as a whole, the provinces and municipali
ties. These surveys for their part revealed geographic differences in health.
Changes in the state of health could now be clearly detected over the years. A
community where initially the local investigator had been his own master, was
now, so to speak, carried off to the offices of the Ministry of Intemel Affairs,
where it became possible to obtain a good overview and to predict future
developments. Henceforth, the Ministry came to function as a scientific centre
stimulating new research and revealing new facts. Already after a few years one

345

from
e 8eneral “"Cleons about the cause of common diseases. Thus
from the very organ.zation of statistics
of accumulation of knowledge, leadine ‘hem hygienists gave a sbmulus to a cycle
to an enlargement of research. They
—i in each part of the a
country. This
! .tOrl,!e hygienists, who alsoJ came to be
- -.-^„i knowledge’.
The effects of demographic change™ ona standardization
Th/Zm UU" of research
reSearch Poores,
_ for
on the
the death ra 7ere “llcillat«l along
established lines. The Dutch Society
Society ttn
for the Promotion
a protocol for topographical studie/
Pr°n’ollon of Medicine also set up
r-o"—OIL
on Pettenkofer
’
s
’
Bodentheorie
’
.
P Un ‘ the ,880s this Protocol was based
Pettenkofer’s ’Bodentheorie’.

The hygienists
hygienists rejected"
°f 'he definit'on of diseases,
The^
rejected the^'lon'tag'iomstic0
method of describing species and eenera wJ/>nSUniPll0^S and the. ^’^onal
wording to outward aspects, which all charact/™^
according
i°f c,ass,fying diseases
epidemiology. In then view the previous con^X Z
ontological. Diseasesjvere
___ not entities which could llounsh^d dm fohowine
environmental changes, but

cal relations in the’bixl'y 'itse^FTo^the* l^oX anHalom'caJ “d Physiologi-

classified i---- ■
Showing their anatom.cal^X
causes of dX6'1*1 d'S°rder' Consequently, mere
decrease in possible
there was
was aa decrease

fixed scheme'ofXsiSon'of d'sX an^"cluse?! ’X followinE a

and a fixed
a as compa-

mor. easily dislmle.ierl rhXe’'‘hfll C01'1'’

quently, the hygienists succeeded in nia^;8 ’.k01
and true. Consethe political debate on health care. P
6 nat,on’s health’ in lhe centre of
The political effects of the statistical rhetoric
soon became noticeable. Members of parliament and ministers made increasing
disputes with opponents. Ever more rf.
• - ‘ J use of statistical facts in
trequently facts came to stand in opposition
to opinions. Ever more the discussion
a on the nation’s health was dominated by
the hygienists’ ’positive science’. C.
Consequently, for the political and social groups
who had participated in this debate j
since theStatistics
eighteenth century, the capacity to
offer an analysis of their own decreased.
differences in mortality between countries, cities and now had the final word:
quarters existed year after

346

differe,,ces ,were structural and resulted from social conditions. Thus,
through their statistical intervention, the hygienists diminished the possibilities
for negotiating about facts in the field of public health.
New legislation
pie introduction of the new medical laws in 1865 marked aa C...V
time v."
of uiumuii
triumph iui
for
the hygienists, because these laws fully confirmed their opinions. The introducti
on of uniform medical qualification provided equal quality health care for
everyone. In addition, the government allocated more responsibility to the local
authorities.
I865 StatC HeaJth inspectorate Act was not much more than a basic law
intended to encourage local authorities to fulfill their responsibilities. Its main
device was the stimulation of research on public health. Local authorities shoulc
take the results of this research seriously and act accordingly. Only if the
municipalities obviously failed in this, did a ’douce violence’ from the central
government become justified to some extent. The scientific research, that was so
vital to this scheme, was to be earned out by fourteen (adjunct) inspectors and
by the members of seven medical councils of the State Health Inspectorate.
Most of them had been hygienists since 1850. They started a research program
me con brio and at the same time recommended improvements. They also
proposed several amendments in the law.
Since they based their reasoning on Pettenkofer’s ’Bodentheorie’, environmen
tal protection played an important part in their activities. They aimed at the
improvement of ground and surface water, though without much effect. For the
purpose of the removal of faeces, a cheap pail-closet system was propagated.
They turned against the so-called flushing system, so successful in later years
However, no new legislation was obtained in this field. With respect to drinking
water, water works were opposed, as long as these would benefit the better-off
only. According to the hygienists, the cleaning up of ground water was a better
means of improving drinking-supplies, because this would benefit every citizen.
On a local level, the hygienists did not achieve much. Although much research
still remains to be done, it seems clear that the hygienists seldom succeeded in
convincing the local authorities of the necessity of governmental intervention.
The hygienists came into conflict with the old liberal view that the authorities
were not responsible for establishing a sound system of public hygiene. The
great sanitary reforms would be carried out by another generation in another
political context.

of new medical theories and a new way of thinking about the nation’s health,
breaking with the paradigms of the old class-ridden society and fitting in with
the liberal-democratic state that was created in 1848. At the same time, the
hygienists acquired the doctors’ support - albeit not unanimously - for the’ new
order. In a sense, the hygienists successfully encouraged Dutch doctors to
participate in an emancipation movement of the learned middle classes in
society. The hygienists, therefore, can be considered as the doctors who political
ly and socially worked out Thorbecke’s 1848 legislation in the field of medicine.

K)
bJ

The
Dutch nygiemsts
hygienists accomplished so 1little ...
me fact that
uiai the
me uuten
v,
in comparison, ,for
example, with their British counterparts should be explained. It is argued that
sanitary measures had by necessity been more drastic in Great Britain, because
the growth of industrial cities had taken place much earlier than in the Nether
lands.
The significance of the hygienists does not so much lie in the area of the
concrete legislation and local regulations that they helped to achieve. Rather,
they succeeded
on agenda. Moreover, they
‘ in putting publicthehealth
political
raised many sanitary problems and produced solutions, which were built upon
after 1880. More important, however, was their contribution in the dissemination
347

348

— 11 Ax.it-

.<&J:..?.>

1 ilfl

.

//y-- J
46

Genetic Screening and Counseling: Chapter 2

Ethical and Legal Implications

47

need t0 communicate personally
or be identified. WheiT^mh^feguards are in place, it seems
likely that screenees would be wmTTtjKaJiave genetic informa
tion released to relatives at risk on eitheTsTtfe-oQri adoption.

Autonomy
k-lCommission believes that the principle of autonomy,
which holds a high place in Western ethical and legal
traditions, is important not only in the relationships of individ
ual patients and health care professionals (through the require
ment of informed consent) but also in the choices that people
make about the use of genetic services. Ethical and legal
implications would therefore arise immediately were participa
tion made compulsory by law, but they can also arise as a
result of more subtle forms of pressure.
Voluntary Programs. One of the central ethical issues in
screening and counseling is that of voluntariness. There are
two main questions: Should participation in screening and
counseling programs always be voluntary? Should treatment of
genetic disease detected through screening always be volun
tary? If the general legal and ethical requirement of informed
consent for medical procedures is applied here, the answer to
both questions would seem to. be yes. Although four major
arguments have been offered to justify compulsion, the Com
mission finds that only one—the protection of those unable to
protect themselves—has any merit, and then only under
special circumstances.

S'
>§/>•

>

the record should be unsealed and the information
communicated to the adoptive family? But most adoption laws
were\ot written with such contingencies in mind; existing
provisioba may be inadequate to address the circumstances or
to provide^rocedures under which the record can be unsealed
so that genetic information can be communicated to either the
biological or adoptive family. The U.S. Department of Health
and Human Services’ recent model state statute for "children
with special needs\fthat is, children with characteristics that
constitute a barrier to adoption of the child) would require
inclusion of a genetic niatory and provides for supplementing
this material for at least WKvears after the child reaches the age
of majority? Provisions lik^these are needed for all adoptions.
The Commission recommendsXhat law reform bodies, working
closely with genetic professionals and organizations interested
in adoption policies, seek changba ‘in the adoption laws to
ensure that information about senl ms genetic risks can be
conveyed to adoptees or their biologit families.
The Commission further finds that tb goals of preserving
confidentiality and preventing harm can »st be advanced if
genetic counselors act as mediators in theyirocess of identi
fying relatives at risk and communicating relevant information.
The counselor already is part of a confidential\elation8hip in
which sensitive information about the risks of genetic disease
are discussed. That "circle of secrecy" need only be extended
slightly to the confidentiality that surrounds an' adoption
record if important genetic information Is provideli to the
relatives by the counselor? In most cases, the biological and

To save society money. Some might argue that compulsion
is warranted if it is necessary for the control of health care
costs. That is, individuals may rightly be compelled to partici
pate in genetic screening and counseling and to undergo
prenatal therapy or even abortion in order to minimize
society s burden in caring for individuals with serious genetic
defects. The chief objection to this argument is that it rests
upon a general principle that few, if any, would wish to see
consistently implemented—namely, that a person's freedom to
make the most intimate choices, and even a person's very
existence, depends upon the degree to which social utility is
maximized. Even were it morally permissible to employ
utilitarian calculations in the extreme circumstances of socalled lifeboat or triage situations, it would not follow that it is
permissible to do so in a society as affluent as the United
States, especially when other means of husbanding resources
are available that do not pose such a direct and profound
threat to the commitment to equal respect for individuals. The
Commission finds no basis in the maximization of social utility
that justifies compulsory participation in genetics programs.
Rather than finding utilitarianism particularly appropriate in
determining social policy on genetics programs, the contrary

• Gilbert S. Omenn, Judith G. Hall, and Kenneth D. Hansen, Gertie
Counseling for Adoptees at Risk for Specific Inherited DisorderiL 5
Aw. J. Med. Genetics 157,156-59 (I960).
\
• § 303(f)(5), Model Act for Adoption of Children with Special Needk
Final Legislation, 46 Federal Regis»«r 50022 (Oct. 8,1981).
\
8 A.M. Capron, Tort Liability in (
tic Counseling, 79 Colum. L. Rev.
819, 680 (1979).
i-

C,Q M H - Q 5

69

ISSN 0234-1475

COM(94) 202 final

DOCUMENTS
16 05

EN

Catalogue number: CB-CO-94-220-EN-C
ISBN 92-77-69250-2
Office for Official Publications of the European Communities
Lr2985 Luxembourg

16
COMMISSION OF THE EUROPEAN COMMUNITIES
COM(94) 202 final
Brussels, 01.06.1994
94/0130 (COD)

commttntcattqn from the commission
and
Proposal fora
r AND COUNCIL DECISION
FUROPEAN PARTIAL

adopting a programme of Community action on health promotion, information,
educadon and training within the frameworic for action
in the field of public health

■

•-

■

•-*

•

•

(presented by the Commission)

•

■

■

■■ w

TABLE OF CONTENTS

L

INTRODUCTION

3

H

HEALTH PROMOTION: CONCEPTS, OBJECTIVES
AND SCOPE

4

IL1 Concqrts and1 objectives of health promotitm
IL2 Scope of health promotion: healtii determinants
IT 2 1 Determinants related to personal bdiaviour

(a)
(b)
(c)
(d)

nutrition
alcohol - tobacco - drug dependence
physical and mental health
medicines and medication

DL2.2 Socio-economic conditions and qiecific population groups

HL

OVERVIEW OF HEALTH PROMOTION TRENDS
AND ACTIONS AT COMMUNITY LEVEL

14

mi. The health promotion approach
m2. Actions already taken at Community level
IV.

THE COMMUNITY APPROACH

19

V.

A COMMUNITY ACTION PROGRAMME ON
HEALTH PROMOTION (1995-1999)

20

V.l.
V.2.

20
21

Objectives and means
Priority measures under the programme

B.
C.

D.
E.

V.3.
V.4.

Health Information
Health education
Vocational training in public health and health promotion
Specific prevention and health promotion activities
Healtii promotion structures and strategies

Otiier instruments of Community action
Cooperation with international organizations and third
countries
................................

30

••

32

VL

CONSULTATION AND PARTICIPATION

34

VH

EVALUATION AND REPORTS

35

I

2

18
L

INTRODUCTION
1.

In its Communic*tion of 24 November 1993 on the framework for action in the field
of public healdi^\ the Commigamn defined a fiamework for future action at
Community level in order to attain the objectives on health protection laid down in
Articles 3(o) and 129 of the Treaty establidring the European Community. The role
of the Community is identified as underpinning die efforts of the Member States in
the public health field, assisting in the formulation and implementation of objectives
and strategies, and contributing to the provision of health protection across die
Community, setting as a target die best results already obtained in a given area
anywhere in the Community.

2.

On the basis of an eramination of die main causes of mortality and morbidity
inHiiding an analysis of die main health determinants or risks implicated in these
causes, together with the most efficient means of dealing with these problems at
Community levd, the Commisrinn identified the jniority areas for possible proposals
for* muhianmia! action programmes. Future strategy will be based on the one hand on
general measures concerning health promotion, information, education and training,
and health data and mdicatora^ and on the other hand on action speofic to certain
diseases or other nuyor health scourges. It is worth noting that measures aimed at
providing health promotion, namely health information and education, have been
specifically identified in Article 129 of the Treaty for Community action in die field
rf public healdt

3.

In die European Community, the major causes of mortality and morbidity are no
longer due to inftgriom diseases. This is reflected in the Commissiou’s
Communication of 24 November 1993, which shows that the nuyor causes of
mortality and morbidity are now due to:

cardiovascular diseases
cancer
accidents, and
suicide
in which lifestyle plays an important role: unbalanced nutrition, alcohol and tobacco
cnncrmprion, lade of physical exerdee, etc. In this context information, education and
training measures aimed at health promotion by increasing awareness of die role of*
these factors and at improving healthy behaviour and lifestyles, can play a key role
in the overall health strat^y and help direct limited resources to maximum effect

4.

In this Communication the Commission sets out the measures which it is proposing
to improve health promotion based on die knowledge and experience it has garnered
from past efforts. Health promotion activities (including in particular health
information, education and training) have been undertaken already for a number of
years at Community level. These have been pursued not only in die context of

Cl)

COM (93) 559 final.
3

19
disease-specific programmes, such as cancer and AIDS, but also as a response to
Resolutions of the Council of Ministers for Health and for Education, and to
Resolutions of the European Parliament which have recognised them as an important
component of a global health policy and strategy. In its Communication of
24 November 1993 the Commission indicated that health promotion actions should
actively seek to modify attitudes, behaviour, and environments, in order to promote
the pursuit of a healthy lifestyle. It has many facets which impact on both the
individual and on society as a whole. It is a complex task which is interwoven with
the entire social and economic infrastructure. Improvements in such an infrastructure
will have a positive impact on health. Thus health promotion measures and those
leading to the improvement of social and economic conditions, have to go hand in
hand. In order to be most effective, health promotion has to involve the whole
community in a joint effort that gives a continuing sense of collaboration and
participation to everybody and leads to the long-term improvement of general living
conditions and lifestyles.
5.

a

The development of health promotion measures and in particular health information,
education and training directed at lifestyle factors and individual behaviour, must also
take account of environmental and socio-economic conditions of the community in
question. It follows that a range of policies may also contribute to achieving the aims
of health promotion, as is set out in Article 129 which states that health protection
requirements shall form a constituent part of the Community’s other policies.
HEALTH PROMOTION: CONCEPTS, OBJECTIVES AND SCOPE

IL1 Concepts and objectives of health promotion
6.

The health of an individual can be characterized by three sets of factors:

endogenous factors which are inherent to each individual, and which are the
result of genetic heritage and anatomical and physiological characteristics;
behavioural factors in which health determinants play an important role and
which are under the control of the individual (nutrition, alcohol, tobacco,
physical exercise, drugs, etc.), all of which may be influenced by societal
factors, culture, education, training and information;
environmental factors and socio-economic conditions, which are related to
the community in which the individual both lives and works.

7.

Health policy still tends to be perceived by the general public as a system for
providing care and treatment by looking after the sick, the disabled and the victims
of accidents. In contrast, the health promotion approach, which stems from the
principle "prevention is better than cure", is aimed at addressing problems at their
source, i.e. encouraging the individual to adopt a responsible lifestyle and behaviour,
and encouraging the community to provide the various population groups with the
skills and knowledge to live a healthy life and to have the necessary socio-economic
conditions and physical environment conducive to good health.
4

20
The primary focus of health promotion must be health-oriented rather than diseaseoriented. It does not concern itself with care, treatment and physical assistance but,
if carried out effectively, it can lead to a reduction in the costs of treatment and care.
All Member States are concerned with containing the costs of treatment and care, and
in its Communicarion of 24 November 1993, the Commission described the
diallenges facing them: an ageing population, increasing population mobility, changes
in lifestyle and working conditions, growing health demands on the part of citizens,
’ and sodo-economic problems. In this context, the “health promotion* approach, which
invests in health so as to reduce the costs of care and treatment will hdp to contain
costs and thus hdp the Member States to provide a high standard of health for the
population.
9.

The overall aims of health promotion in the European Union both at European
Community and Member State levd may be summarised as follows:

to promote and support the provirion of information and education on
bealtiiy lifestyles, in particular balanced nutrition, appropriate physical
»rtivity safe sexual behaviour and positive health behaviour such as the
avoidance of smoking and addictive drugs, moderate drinking and sensible
ways of reducing and coping with stress;

to improve the standard of health of all European citizens, and in particular ....
disadvantaged population groups;
t

.

J

to provide individuals with the information and knowledge needed to take
action against the occurrence of disease, accidents and injuries;
to allow citizens to take action so as to develop and use their full health
potential in order to improve their quality of life.

n 7.

10.

Scope of health promotion: health determinants

At the centre of hralth promotion activities lie the factors which determine the health
of the population and winch can be influenced by health promotion measures.
Some of these factors are a matter erf individual behaviour and choice, others result
primarily fixxn socio-economic circumstances which require action by the community
as a whole. The ultimate objective must be to improve the situation (awareness and
behaviour) as regards these factors for as many people as possible. It is important that
the messages conveyed by health promotion measures must be seen as positive, as
scientifically justified and as dear as possible. Conflicting, vague and unproven
messages can only be confusing and counter-productive.

5

21
II.2.1

Determinants related to personal behaviour

11.

The main health determinants and risk factors; over which the individual has some
^^roTimd for winch he/she may exercise discretion are as follows:

nutrition,
consumption of alcohol, tobacco and drugs,
- physical and mental health,
medicines and medication.

.
(a)

Nutrition

12.

There is a wealth of variety in thelbod available in Europe today. Europe's wide
rme of eating habits has developed as a result of a multitude of pressures:
geographic, climatic, economic and social, and it is still evolving in response to
nu^nTsociety. The ready supply of affordable food, however, has resulted in
changes in food consumption patterns and has led, in some cases, to overeating,
S and associated ill health. Diet plays a role not only in relation to heart disease
and stroke but also to cancer. Circumstantial evidence indicates that perhaps as much
as one third of the deaths from cancer in devdoped countries is due to diet In
addition, it is becoming increasin^y evident that nutrition is an important determinant
of several other conditions such as diabetes and dental caries.

13.

In recent years the general public has become much more aware of the importance
of nutrition in protecting health and preventing disease. Several factors may, however,
main, ft difficult for people to adopt a healthy dietary pattern. Economic prosperity
and snrial awns have influenced dietary patterns in all European countries,
particularly in the last generation; for example, cereal and potato consumption have
decreased, while meat and dairy products figure more prominently. Tradiuondly
prepared meals are increasingly replaced by processed and manufactured foods. This
is not necessarily a negative development, but requires a
from the public; people must be able to read and understand food labels instead of
flavourings, colouring matters, labelling, padcaging, hygiene, anh-ondmts,
contaminante and residues and particular types of food and beverages. These
developments reflect the dedine of traditional food culture and meal patterns. In
addition, today's family often takes its meals outside the home, and the quality of
these meals depends also on the caterers' knowledge of nutrition. Dietary pattons
often change when people move to another region or Member State, since tiiqr &id
them itrl ves
to a food culture which is different from that with which they
grew up. It is likely that such changes will occur even more frequently in the future.

14.

The mass media also play a very influential role. A great number of articles in the
press and of radio and television programmes deal with nutrition and pass on a
variety of messages and recommendations while people are also exposed to a great

6

22
variety of audiovisual commercials concerning foodstuffs. The area of nutrition
suffers particularly from confusion in the messages conveyed by the media and
fashiomd>le trends and social pressures for excessive slimness. An important task of
this programme must be to try to promote a better understanding of basic principles
in the area of nutrition and diet which will enable the consumer to better appreciate
and use the informatinn provided by nutrition labelling. In addition, the consumer will
be made aware of the valuable information which appears on labels such as the list
of ingredients, the instructions of use, the expiry dates, etc and their significance.
15.

Amongst the positive messages to be conveyed is the desirability of wider
consumption of fresh fruit and vegetables. A better awareness of when such
fond stuffs are plentiful and cheap to buy, or of ways of preparing and preserving
them properly at home can overcome the argument that such products are too
expensive. Increased consumption of fibres and a better balance between them and
protein and fat consumption are desirable. Increased consumption of fish and fish
products as a source of proteins, polyunsaturated fatty adds and oligoelements are
also important for health, in particular in relation to cardiovascular and mineral
deficiency diseases. Some of these products are cheap and widely available (fresh
frozen canned, etc.) and their increased consumption is a question of habits and
education.

Improved nutrition is not only a matter of eating at home but also one which needs
attention in restaurants, mass catering establishments including school canteens,
residential ingfituitions, and fast food outlets
16.

Another message which has to be conveyed in unequivocal, yet acceptable terms,
concerns the need to monitor and, if necessary, to reduce intake of saturated fats, salt
and sugars. Closely associated with this matter of diet is the need to protect against
food-borne diseases such as salmonella and listena brought about by food
contamination, poor hygiene, inadequate food production and storage or cooking
arrangements.

17.

There are some groups of the population which are particularly at risk today but
which are not traditionally regarded as nutritionally vulnerable. Old people may find
it difficult to adjust to the rapidly changing food culture, or may have poor nutrition
because they live alone. Infants may be at risk because parents are sometimes
uncertain about how best to feed their babies. As is usually the case, the lowest
socioeconomic groups are least well informed and find it particularly difficult to
adopt a healthy diet, and in addition, faced with a confuting new food culture, they
may not get the right information about what to do, and how to interpret messages
which are sometimes conflicting or unclear. The results of this inequity contribute to
the socioeconomic differentials in premature mortality from diet-related diseases.

7
(2)

23
18.

It is worth noting, in this context, that the Commission proposals for an action plan
on cancer 1995-1999<2), include the continuation of the important European
Prospective Investigation of Cancer, Nutrition and Health (EPIC), which involves
cohort studies on cancer, diet and health, including the monitoring of some 350.000
subjects over a ten year period. This study and epidemiological studies on research
into nutrition as a potential preventive factor, identifying protective agents and
modifying specific dietary factors, will also produce vital information for other major
diseases such as cardiovascular disease.
(b) Alcohol - tobacco - drug abuse

19.

The drinking of alcohol is a common practice in all the Member States of
the Community and the production of alcoholic drinks - spirits, beer and wine -is an
important part of the economy of most of them. Alcohol plays an important part in
social life and gastronomy and certain reports suggest that moderate consumption has,
in some circumstances and for certain groups, been found to be beneficial to health.
In terms of pure alcohol, total EC consumption in 1990 amounted to 3187 million
litres a year, which equates to 9.8 litres per capita. Per capita consumption rose by
8.4% during the 1970s but fell by 14.5% in the 1980s. Consumption varies between
Member States in terms of the types and volume of alcoholic drinks consumed
(26637 million litres of beer, 13696 million litres of wine and 1819 million litres of
qjirits in 1990), the expenditure of consumers on them, and the proportion of tiiat
expenditure to overall consumer expenditure. The consumption of pure alcohol per
capita in 1990 varied from 12 litres in Ireland to 12.7 litres in France but the
proportion of the consumer budget in Ireland was 12.1% whereas the proportion in
the Netherlands and Spain was only 1.1%.

20.

Excessive alcohol consumption either alone or in combination with other factors like
smoking or poor eating habits, is a major factor in mortality and morbidity. It can
lead to drunkenness, violence, family and social problems and accidents (particularly
traffic accidents). Effects vary between individuals, being partly rdatod.to sex and
weight Excessive consumption <rf alcohol is particularly linked to liver damage,
mental disease, stomach, mouth and colorectal (with other factors) cancers, and
(when the mother is alcohol dependent) foetal damage and miscarriage, and perhaps
implicated in other diseases as well.

21.

Tobacco- The Community's action plans to combat cancer have from the beginning
■ reengnizrd the importance of tobacco as a major causative factor in the devdopment
of several types of that disease, particularly lung cancer. The Communication

<2)

Commission Communication concerning the fight against cancer in the context
of the framework for action in the field of public health, COM(94) 83, and
proposal for a Decision of the European Parliament and the Council of die
European Union adopting an action plan 1995-1999 to combat cancer within
the framework for action in the field of public health (OJ No C ...).

8

24
concerning the Commission's Third Action Plan on cancer recognises that more recent
ZZX data show that about 30% of cancer deaths are due to tobacco. Tobacco is,
assisted with increased mortality rates for a number ofother major
cardiovascul^ disease and pulmonary disuses other than lung
accepted that passive smoking is associated with canoos, acute
disewe -d ped-m- dis««
<tat «h=r toons
of tobacco consumption have similar effects.

22.

r«nmunitv action to combat tobacco, mainly carried out as part of the Community

remains to be done, pytiodariy m
young
and^bSened to cover fully the dangers oftobacco
disasK
th.
combination with other risk factors such as alcohol.
23.

« •«*—

the Commission's proposal for -Community action in tite field of
sets out the present position in the Community on this subject
^^7^X1 to taken at Community level. The proposed measures cove- the
and ipeafic action to be
,
the abuse <rf phannaccutical products
r>,«,

and the “““se rf chenu prodt^
increases
drug-related mortality and
ZXbidity increasrrf'numbers of requests for treatment and increased numbers of first
Zhigr It notes the high percentage of drug use among prisoners and
Sowing mXSrf AIDS cases linked to drug abuse with accompanying anxiety

about HTV-infection.

p>

rzwnmieson Communication on Community Action in the field of Drug
fCOM(94)
) an^ proposal for a Decision of the European
SX «n(ddS'cii of*' Europe™ Woo esablisbing • P"^™”'
of Commuiuty ecdoo on the prevention of drug dependence (01 No C...)
of Comtnunrty •“
' fta jn the content of the Comnusaon
?**
CO^m^ aS on the ftmework for public hedth
S^tata^ntitof-h. fonne GtobJ Pl« Wrina Drugs

SSr
’ii™ " ,nide l2’ rf the EC T,rT,r
nreiudice to possible international cooperation actions ofthe Union in th

SXk ifAe Common Foreign and Security policy and of_ti«
cooperation in the fields of justice and home affairs, concerning the figh
against drug and drug dependence.
9

25
24.

While current and proposed actions specifically target aspects of drug abuse and
people who are either already drug users or in population groups or settings at high
risk of drug abuse, the Community's programme on health promotion needs to
intrgrate messages, information and advice on the subject with those on other health
determinants and risk factors to assist the general public and certain population
groups, such as young people and their families, whidi would benefit from better
knowledge in order to adopt behaviour and take decisions conducive to health.
Similariy, health and education staff need to be informed about drug abuse and the
subject has to be included, together with other risk factors, in both basic and post
qualification training courses.

(c)

Physical and mental health

25.

Physical
Modem life is frequently sedentary and many people by choice or
circumstances do a minimum amount of walking and avoid more vigorous exercise.
The lack of adequate physical exercise is a determinant in certain diseases and
conditicms such as cardiovascular disease, physical disability and
Encouragement to take more exercise, in whatever form is satisfying to the individual,
is important for all age groups, including children and the elderly, and is by no means
confined to the practice of sport or gymnastics. Physical activities and sport can also
help to combat stress among young people, students and people at work.

26.

The positive message is to choose forms of physical exercise that will provide interest
and be undertaken regularly, while being sufficiently vigorous to keep the body m
good working order and relieve mental stress. Activities to promote more exercise can
range from those undertaken in the home or garden to those requiring speaal
facilities, equipment or organizations. The particular needs of those in instituUons
such as did people's homes may need carreful attention and require promotion
measures that are specially suited to the circumstances.

27.

Mental health. This important determinant of health has received relatively htUe
attention at Community level despite the extent of its effects on the wxmomy and the
quality of life of the population. Some 5% of the population is estimated to sutter
from serious mental disorders but an additional 15% of tiie population is
to suffer less severe forms.
The progressive ageing of the population in the Community is likely to increase these
figures as the prevalence of dementia is strongly age-related. S«3
ev op.
,
also likely to increase the prevalence of mental disorders as the result of increased
stress and weakening systems of social support.

10

26
28.

The levels of suicide in many Member States are an important indicator of the worst
effects of these developments. Suicide is a leading cause of death for women aged
30-34 years and for men aged 3S-39 years. In 1989 it caused between 6% and 11%
of deaths among women and between 9% and 15% of deaths among men in the age
group 15-44 year in the Community. In some Member States deaths from suicide out
number deaths from traffic accidents.
Stress and depressive disorders, which may lead to suicide attempts, are clear
priorities for action. Improvement in public awareness and willingness to understand
and assist those suffering from mental distress could also be very beneficial.

29.

'TVz.’fjd/fa.'L The risk factors giving rise to accidents and injuries are of
Risk-takinp behaviour:
particular importance in childhood and early adult life, when their incidence cmnbined
witii the resulting number of years of life lost or disability suffered are at their
highest Home, sport and leisure accidents are common in childhood, while traffic
acddents are the major cause of death for both males and females between the ages
of 5 and 29 years. In the 15-24 age group mortality caused by accidents in 1989
accounted for over 35% of all female deaths and some 55% of all male one?. Overall
deaths related to acddents over the period 1960-1990 remained fairly consistent at
about 7% of all male deaths and about 4% of all female deaths.

30.

The common dictum "accidents will happen" is symptomatic of a fatalistic attitude
to accidents whidt needs to be changed into a belief that accidents can be prevented
if sensible precautions are taken. This programme on health promotion will underpin
the efforts of Member States to incorporate general messages about prevention, choice
trf1 safe products and where necessary training, in order to promote a sensible attitude
to safety in the population as a whole.

31.

Sexual hv^ene and bchaviair The threat to health posed by AIDS over the last
decade has tended to overshadow the importance of other forms of sexually
transmitted disease, such as gonorrhoea, syphilis, and herpes. Furthermore, the
spread of these diseases has led to a higher prevalence at present in Community
countries than cases of AIDS or even HIV infection. In this context, health
information and education can have a beneficial impact on the physical, mental and
social state of individuals, especially tire young.

32.

The role' of health promotion in sexual matters is undisputed. The task of integrating
and conveying messages about sexual behaviour and attitudes will be supported
within tiie overall context of this health promotion programme, and will be completed
by actions which the Commission will propose in the context of the specific
programme concerning AIDS and other communicable diseases.

33.

Personal hveiene'. It is tempting to think that matters of personal hygiene are no
longer a cause for concern in the Community. This is, however, far from the case,
espedally in deprived areas or among marginalised groups, addicts or isolated and
often disabled elderly people living on their own. Such situations demands preventive
action targetted towards those population groups most affected, by providing

11

27
A ■ C

and basic health education. There is also a need for more

St ie^xir^“ad- fpXxt
environmental conditions.
(d)

Medicines and medication

34.

well as infonnation for health professionals.

35.

with0ut P™8®^011 This is
™J?^lt of people’s desire to take responsibility for their own health and partly
^to^Xgen^L of messages transmitted through themedia onthe subject of
Sensible self-medication may also help to reduce health expenditure
J^^&e number of medical consultations. The trend towards sdf-medication
muX^comp«nied by a strengthening of information measures if it is not to have
.riverne effect on people's health. Thus giving people more choice and
J^Sty^ust also^olve ensuring that they are equipped to make sensible
choices.

36.

37.

THs pnrfce is of particolsr benefit io the treament of minor nilinenB sod on
.wnvJL relief from these for the persons concerned- However, the public must be
S^e eS^nperlv mfomted of the need to consult . doctor if
JX or doubts mdsut may occur thst after irnttd dugnems pnd presotimot sdf^Xn is possible with the doctor delegating control whde reaimog an advisory
S^Xs tatte <« of diabetes and asthma. Information .n all these msamust
S eX accessible and easfiy imdersandable. Other aspects of the use rf products
JXXd to sdf-medicalioo must be emphasised and taken into actounk such as
repeated and excessive use of certain types of drugs and the proteOroo of chrldren
from accidental poisoning.

Pharmacists have a key role to play in providing assistance, advice and information
tailored information material and appropriate training.

12

28
38.

Doctors who prescribe medicines can have an important role in raising people's
awareness concerning the consumption of medicines and, indirectly, tn the efforts to
control health costs. Providing information to doctors and pharmacists about
availability of different pharmaceutical treatments may also lead to a cheaper
treatment with equal results. Providing sufficient information to consumers can also
contribute to a more sensible use of medicines.

n.2.2 Socio-economic conditions and specific population groups
39.

The state of health of a community depends to a certain extent upon the prevailing
physical environment
and socio-economic conditions. Within the Community, where
Tiwi
±e overall health standard is among the best in the world, there are differences in life
expectancy, mortality and morbidity between groups, related to differing socio
economic conditions. The main social and environmental conditions which are of
decisive importance for health are housing and urban planning, quality and level of
education, employment and working conditions.

40.

Action to improve or compensate for existing economic and social conditions of
Heririvr importance to health comes under various sectors, policies and areas of
responsbility,
taring an intersectoral approach and genuine partnership between
the government authorities, health professionals, local and regional authorities, health
and social organizations, and the population groups concerned. Improvement of the
overall health level in Europe must take account of the unfitvourable conditions of
certain groups (die excluded, poor, elderly, and immigrants) and communities (innercity, peripheral and rural areas) either because they are more exposed or more
sensitive to certain risk factors, or because their socioeconomic conditions are
unsatisftetory, or because their behaviour and lifestyles make them more vulnerable.

41.

The proportion of elderly persons aged 60 or over in the Community is increasing
From only 17.5% in 1980, it is expected to rise, according to some estimates, to 24%
by 2010 This will lead to both a gradual rise in the number of dderiy people, who
are major users of health services, and a relative fall in die number of active persons,
who will have to foot die bill for diese services. This means that health care
requirements threaten to exceed what society is able or willing to provide.
Furthermore, studies have shown that reduced mortality among the dderiy is
accompanied by an increase in chronic disabilities, and that the average number of
years of invalidity has risen more rapidly than die number of years of good health.

42.

As oudined in the Commission Communication on Public Health of 24 November
1993 ( COM (93) 559 final ) there is an increasing intermingling of populations in
die Community The health implications of this devdopment are complex They
include the introduction and spread of diseases hitherto not encountered, renewed
nnthrealni of diseases which had previously been eradicated, the varying
susceptibility of different groups to common diseases, and the health risks and
problems arising from the socio-economic conditions in which some groups are
obliged to live.
13

29
43.

HL

Special attention must be devoted to adolescents and young people, as it isthe
experiences and choices made at this period of life that help determine future
and behaviour. These experiences and choices are particularly critical in respect to
alcohol and tobacco consumption, drug dependence, sexual experience and, generally
speaking, the adoption of positive behaviour with regard to life and society.
OVERVIEW OF TRENDS AND ACTIONS AT COMMUNITY LEVEL

HLl The health promotion approach
44.

The momentum for the development of health promotion in
during the 1980s and early 1990s has been encouraged by several
and resolutions, important conferences, reports “dpubh^°“*“w
past
Commission, the World Health Organization, and thcuCounC,?f
S^
the content of health promotion activities undertaken m
related mainly to the prevention of speofic diseases such as cancer, <anhovasodar
dsXs, drug depended, infectious and communicable diseases, AIDS, and the
prevention of accidents.

45.

impact on health of lifestyles as well as everyday living conditions.
46.

Member Su.es, m plmmieg their hedth promodoo ecdvWes. tave
that lifestyles and cultural and socio-economic conditions areinextn
?
Consequently, health is now bang considered throughout Europe m a ®
X
& scope of health promotion activities tas been bnmdmted »° thm «
improvement tabealth and well-being is now seen as an important element
determining the quality of life.

47.

The adoption by many Member States of the WHO'S prognrnrme “2*,““ X™
bv the year 2000" has contributed substantially to developing th
of health promotion in Europe. Numerous activities m
carried out, centred on the targets concerning equality in.herith’
tL_lrtiri2 a
achieving a better health status, promoting lifestyles conducive to h
,
8
healthy environment, and establishing appropriate care.

w

Commission's actions in this field are reported in
Commisson such as the report on the execution o
lamentation of
against cancer (COM(90) 85 final), the report on the,
hS± education in schools (SEC(92) 476), the report on dmg demand
reduction (SEC(92) 725 final) and the report on the implementati
first action plan on AIDS (COM(93) 42 final).
14

30

48.

Most Member States have developed national strategies in which the broad
perspective of health promotion has been taken into account The setting up of
Pictures for health promotion at naticmal and regional level has provided
opportunities to intensify health promotion and improve its effectiveness by avoiding
duplication of work through the identification of the common features of health
momotion. Financial and human resources have increasingly been allocated to
organizational devdopment and training in health promotion. Despite this the total
budget spent by Member States on health promotion is small when compared to what
uXntOT treatment and care. The priority settings for health promotion activities
at present are the school, the family, the local community and the workplace. The
priority health promotion issues cover nutrition, tobacco, alcohol, drags, accidents and

AIDS.
49.

50.

In its Communication on the framework for action in the field of public health the
Commission recognizes the importance of several major chsnses (from the point of
view of mortality and morbidity) but concludes that several of than can be addressed
by existing programmes and by future health-promotion action of a general nature
Th^. indude cardiovascular diseases, mental diseases and chrome diseases such as
musculo-skdetal disorders and diabetes. Health promotion activities under this
Community programme will provide the opportunity for health professionals and
interest groups to make a contribution to substantial and lasting reductions in the
prevalence of these and odier diseases and an improvement in health status.

disease (CVD): There are a number of factors that play a role in the
cdol^yS’both cancer and cardiovascular disease. As a consequence some preventive
actions undertaken within the context of the cancer programme have ato helped in
the prevention of cardiovascular diseases. Similarly, research into the effe^; of diet
on CVD fit wdl within the scope of such large scale studies as die European
Prospective Investigation of Cancer, Nutrition and Health (EPIC). In due comae, the
data and monitoring requirements for CVD at Community level could largely be met
within a "health data and indicators, and monitoring and surveillance of disc^l
programme. Similarly, the health promotion requirements concerning the major CVD
dtt^Zmts and risk factors - nutrition, physical exercise, tobacco - can be
accommodated within the general action proposed by the present programme, other
actions may also be directed towards population groups vulnerable to thisdisease and
health ^dother relevant professional staff can be trained in the
(along with that of other major diseases) m the programme Costfbeneft and
mZX evaluations of acton undertaken to combat CVD will also fit easily mto
th^rallXork proposed for health promotion measures in general, especially given
so many important common factors.

51.

Mental diseases Mental diseases are known to exact a heavy toll in the C^munity
of morbidity and health costs. A considerable part of these is related to care,
institutional and otherwise, of sufferers, for which preventive action does not exist
Fa
rest, however, a lot can be done, and Member States devote ««sid«^®
effort and resources in devising and implementing programmes aiming at
mental health. Health promotion action features prominently among these
15

t3)

nroRrammes, and Commission action in support of these is possible within the :scope
nfrt^ctivities envisaged under this health promotion programme^ Ln particul
°f *
to «eSse stress, and substance abuse, will undoubtedly make an
?CtlOnS nnntribution towards reducing the burden of preventable mental disease,
Fhgraom.e . hmhh dm ~dh»hemo«
^dU ossrsr efforts eiming « idemi^iog cosMive fSoors m memel disorders
52.

rdsonto Moseuloskekeral disorders, mdmling
art bv anv standard, a major scourge m all Member States, ine
rheumatism, are, y Y
in the context of the
Community has
. policy which included the adoption of ergonomic
■^^A^eXS^Adi^oo health sod safett'ss well
pnorsples.theso^ledfime^tt“
mm011l taa.og rf

Ltddii^d incootmence, the Community erm make a comnbrmrm to the efforts
of the Member States.
53.

Didrems is likdy to mise m geooiadly
iSrSd exercise too litde Suffiaeut rrcmue mal the
as^'^gum.Z^iddy

^^i,^.^o^^ircme atd to mdmm. the taahh rfto
X- • .St^lo" a mmd» be

subject of special screening.

nr? actions already taken at community level
European Council
54.

to 1986,
Headt of Sutt md Goverraod meedog
resolutioo on * programme of inion of rhe Emopeen Commumh«l«M«^“
(8<rci84/05f> wtnAserrhe obie^r> <**«MS«„X on
actions to be considered. It also agreed to declare 1989 as a year qi
in
cancer. Moreover it called upon the^abonne^Wbnning
the treatment and rehabilitation of drug addicts m order to

<?>

w
CT)

CD

Council Directive 89/391/EEC, OJ No L 183 ^29.6.1^9.

S SS”

S N°o L ’156 or 21'.6.19».

OJ No C 184, 23.7.1986.
16

32
teachers, parents, and young people about the risks related to drug addiction and in
preparing a report and recommentations on measures than can be taken at Community
level. This serious preoccupation with drugs was reflected in the declarations of
subsequent meetings of the European Council, notably in London in 1986, in Dublin
and Rome in 1990, in Luxembourg and Maastricht in 1991, and in Lisbon in 1992.
The London meeting in 1986 also stressed the importance of coordinating national
campaigns against AIDS with a view to raising awareness and better informing the
public On this disease. These resolutions and declarations by the European Council
paved the way for Community action, including measures relating to information and
education against the scourges of cancer, drugs, and AIDS.

Council
55.

The Council Decision of 26 November 1990 concerning Community action for
elderly peopled” resulted in a programme in 1993 for the European Year of Older
People and Solidarity between Generations. This programme contained measures on
health education for older people. The Council Resolution of 3 December 1990*
concerning nutrition and health indicated that the Community had not up to that time
given overall consideration to aspects of nutritional education and consumer
information with the aim of promoting eating habits in keeping with individual "needs.
It also underlined the importance of providing all Community citizens with the vital
Imowl rrige and education which would enable them, within the framework of their
lifestyle, to make the necessary choices for ensuring appropriate nutrition in keeping
with individual needs. The Council Resolution invited the Commission to propose a
programme based on the aims and guidelines set out in its annex.

56.

The Council Resolution of 3 December 1990<n> on improving the prevention and
treatment of acute hum an poisoning invited the Commission to prepare regular
summary reports for the Community indicating in particular the measures required at
Community level for the prevention and treatment of acute poisoning, and to expand
on specific topics based on the information received fium the Member States on the
prevention of acute human poisoning. As requested by the Council Resolution
Member States have designated competent authorities which have collected and sent
to the Commission the annual reports of their Poison Centers.The Commission is
preparing a synthess report which will be issued by the end of 1994.

57.

In relation tp school health education, the Resolution of 23 November 1988 of the
Council and Ministers for Education meeting within the Council
on the
implementation of health education in schools has proved to be effective in generating
Community action on the identification of a statutory framework for school health

m
(10)

di)

(«)

OJ No L 28, 2.2.1991, p. 29.
OJ No C 329, 31.12.1990, p. 1.
OJ No C 329, 31.12.1990, pp. 6-8.
OJ No C 3, 5.1.1989.

17

33
education, the implementation of health education in the school curriculum, the
exchange of teaching materials for health education and teacher training in health
education (initial and in-service training). The Ministers for Health, at their meeting
of 13 November 1992, adopted Conclusions'*3’ to the effect that the Commission
should pursue coordinated activities in school health educaticm in order to avoid
overlap and duplication of work and especially to improve the effectiveness of those
activities. The Ministers for Health also invited the Commission to take action at
Community level to develop effective models for the implementation of health
education in settings other than schools (workplace, leisure facilities, etc.).

European Parliament
58.

The European Parliament has been in favour of a Community health policy since the
early 1980s and has put forward several resolutions in the field of health. Members
of the European Parliament have always shown a keen interest in health matters, as
is evident from the very large number of Parliamentary questions raised on the
subject its various committees, in particular the Committee on Environment, Public
Health and Consumer Protection, the special Committee on drugs, and the Committee
on Youth, Culture, Education, the Media and Sport, have prepared several reports on
health-related subjects.

59.

Parliament has shown great interest in the area of information, education, health
promotion, and training. On 17 December 1993 the European Parliament adopted a
Resolution0*’ on health education in schools, highlighting the importance of health
education, and stating that there is a need to provide sufficient human and financial
resources to develop heath education policies at Community level.

60.

In its Resolution0” on public health policy after Maastricht, the Parliament calls upon
tiie Commisrion to develop and implement activities on health education and health
promotion, prevention of drug dependence and accident prevention, taking into
account the problems of the elderly, and cardiovascular disease. At present, the
European Parliament is examining the Canmission’s Communication on the
framework for action in the field of public health and is preparing a Resolution on
this subject
Economic and Social Committee

61.

During the past few years, the Economic and Social Committee has given opinions
on health matters such as occupational medicine; dangerous substances, and
preparations; the Community system of information on accidents involving consumer

(U)
(M)

OS)

OJ No. C 326, 11.12.1992, pp. 2-3.
PE 204.337/final.
PE 205.804/final.

18

34
products; occupational cancer, an action programme on toxicology for health
protretinn, etc. More recently die Committee approved Community initiatives in die
jay;,; fidd, sudr as: the Eun^rean Year of Older People and Solidarity between
Generations, die Europe against Cancer programme and die Europe against AIDS
programme.
62.

IV.
63.

At percent, the Committee is preparing an opinion on die Commissions
Communication on the framework for action in die field of public health.

THE COMMUNITY APPROACH
The Commision’s Communication on the framework for action in the field of public
health proposes four objectives which should form the bass of Community action:

CO

to prevent premature death whidt particularly affects the young and working
population;

(ii)

to increase life expectancy without disability or sckness;

0ii)

to promote die quality of life by improving general health status and die
avoidance of duvnic and disabling conditioas;
I

0V)

to promote general wdl-bcing of the population particularly by minimising die
economic and social consequences of ill-health.

The proposed Community action programme on health promotion addresses all these
objectives.
64.

As explained in the Commisson's Communication on public health. Community
action will in particular focus on encouraging cooperation between Member States,
lending support to their action, working dosdy with them to promote coordination
of their polides and programmes, and making better use of Community policies
where these relate to public healdt The Ccmmisson has also explained that partiailar
attention should be devoted to die following activities : health promotion, health
education, training of health professionals and cooperation with international
organizations and third countries, as well as research.

65.

Future Community action in the public health field must take account of the principle
of subsidiarity and die requirement of proportionality. It is worth noting in this
context, that the diversity observed within and between tire Member States in respect
of geography, dimate, lifestyles, culture, sodo-economic conditions and the
environment is such that, generally speaking, no detailed requirements can be
proposed by the Community. Activities must be sdected on die basis of prior
appraisal and should yidd a Community added value while achieving maximum cost
effidency.

19

35
66.

The following criteria in particular will be used in assessing the need for Community
action in the health promotion field.
activities on a scale which Member States themselves could not, or could only
with difficulty, implement;
activity which, because of the complementary nature of work being done at
natioMl lev? enables significant results to be obtained in the Community as

a whole;

activity which leads, where the need is recognised, to the establishment of best
practice standards;
activities which contribute to the strengthening of solidarity tncIwad
cohesion in the Community, and-promote its overall harmonious devdopmen

67.

Community health promotion measures will be based on two types of instrument

measures implemented through the action programme, described below, in
order to promote health in general terms;
activities and measures other than those coming direcdy u^=r.Pub^c “
• fi
With ft beftlinS OQ pUDUC
programme^ especially
omer vommumiy
pwww
health.

V.

A COMMUNITY ACTION PROGRAMME ON HEALTH
PROMOTION (1995-1999)
V.l

Objectives and means

68.

Ztfronmental conditions which are a prerequisite for the health of the individual
the community.
69.

In accordance with the provisions of Article 129 of the Treaty, the Community action
programme on health promotion will focus on.
-^■ahnn hetweM the Member States and promoting

and
supporting Member States’ activities in the fidAof health promotion.

20

36
70.

As far as coordination is concerned, the Community's role will be to encourage
constructive relations at all levels, to help combat any shortcomings that are revealed,
to devise and improve strategies for the effective implementation of policies and
measures, and to ensure transfers and flows rf knowledge, expertise and materials to
the mutual benefit of everyone concerned.

71.

As stated in the CommisMon's Communication on public health the Commission's role
in implicating health promotion and health education will be to:
facilitate die exchange of information and models of good practice by
networking, preparation of information packages, manuals, and workshops;

lend support by providing appropriate incentives;

The Commission will, in particular, support proposals submitted by Member States
amt initiatives involving organizations and agencies active in the field of health
promotion. In addition die Ccmmisson will cooperate with international organizations
and transnational associations active in tins area.

72.

To have the grearett possible effect with the limited resources at its disposal, it will
be important for the Commissi rm to concentrate on die support of large-scale projects
which, in most cases, will involve several Member States. In this way it will be
possible to maxinuse die impact of measures, thus ensuring the visibility and added
value of Community action.
VJ

73.

74.

Priority measures under the programme

In its Communication on public health the Commission has emphasised the global
and complex nature of health promotion activities and their dose link with measures
to improve economic and social conditions. It points out that health information and
health education can be considered as general subjects situated in a large and diverse
area (family, school, work, community), cover many lifestyle-related accidents or
diseases (cancer, AIDS, drugs, canfiovascular cfiseases, accidents, etc.) and aim to
change risk behaviour (smoking, alcohol, nutrition, drug abuse, lack of physical
exercise, etc.).

With regard to certain major health scourges or diseases which represent a serious
public health hazard, the Community’s general health promotion activities may be
supplemented by specific action programmes such as on cancer, AIDS and drugs, w
ireCrenmimifartinn the Commission has stated its intention to review existing
programmes to ensure that measures of a similar nature, such as health promotion and
health education, will be grouped together so as to avoid duplication of effort and
improve efficiency.

21

37
75.

The attached table shows the types of measures which can be implemented taking
account of the main factors described above, namely.
the need to take account of the main determinants or risk factors relating to
disced to ensure complementarity and consistency with the specific

-

Ae^dtTensure added value and efficiency of Community action.
toe need to develop approaches and activities in which aU three main h<^to
promotion tools, namely information, education, and training, are integrated.
A.
76.

Health Information

The basic condition for an individual citizen to be able to adopt
behaviour conducive to good health is that he/she is
represented by a particular factor or type of behaviom and
S^HealA information represents an ongoing and fundamental ^ect of h«l&
^notion It may take the form of wide-ranging mfonnation campugns umed at
JhTLiend publics specific target groups (e.g. young adula, the elderly, children)
in respect ofTspecific risk factor or determinant (e-g. anti-smoking campaigns), using
vJ^XpSIary media (radio, TV, posters). It m«ya^ ««■« » ««
^Zent ^ise using specialised media (health journals, recorded TV or radio

programmes, etc.).
77.

diseases).

78.

At present, the large number of messages and means used in the field of
informatirei and communication may mean that people have problems in
understanding and responding to messages which may sometimes
or even CTntradictory. The Community could contribute towards
knowiedne of the mechanisms involved in die design of messages and in the

Sr?

s

between referatce centres «t naionnl lend «ndJ'*'™'0
knowledgeable about national experiences, stroOttres,
Community activities and programmes in tbe field of public health and
proniotiofL

22

38

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39
79.

The objectives of Community actions in relation to health information are to:
improve knowledge of the psycho-sociological mechanisms involved in
providing health information;
improve health information methods and techniques, including evaluation
of their impact;

contribute to providing people in the Community with information on
specific health factors;
encourage a European4evel exchange of information and documentation
between professionals and those reqxmrible for public health and health
promotion policies;

distribute infbnnation on Community public health and health promotion
measures to those concerned.

80.

In this context the Commission will support actions in the following areas:
-

Increased knowledge of the psycho-sociological mechanisms involved,
health information methods and techniques., exchange atexperience and
dissemination of information on "best practices", assessment of the results
and impact of information campaigns (cost/benefit).

>

Preparation and assessment of specific information campaigns coordinmed
t Community level rr in Mventl Member States. Surveys of public opinion
on the different aspects of health promotion (Eurobarometer survqr).
Transnational networks of reference centers for information and
documentation on public health and health promotion for use by
professionals, administrators and decision-makers ; dissemination to
interested parties (associations, local authorities, public bodies,
admixustnttive eotitie&> professionals) of information and documentation on
Community activities in die field of public health and health promotion
(pd)lications> conferences, leaflets, newssheets, etc.).

B.

81.

Health education

Health education is the cornerstone of health promotion policy. It is through healtti
education that individuals will progress from a ample knowledge of risks, through
awareness of what is at stake in respect of their health, to the adoption of a
responsible and positive behaviour and lifestyle. In the Council Resolution* on
(in

OJNoC 3, 5.1.1989.
24

40

the implementation of health education in schools, health education is defined as
a process based on scientific principles, which employs planned learning
opportunities in order to enable individuals, acting separately or collectivtiy to
make and act upon informed decisions about matters relating to health It is a
comprehensive process for which responsibility has to be taken by the family, as
wdl as the educational and social community. Health education, wherever it
occurs (school, workplace, leisure, etc ), is ideally an interactive process in which
target populaticms are active participants, rather than passive recipients People
must be infonned partners in determining their own health as wdl as the health
of the country, region or local community in which they live.
82.

School health education is designed to give children a sense of individual
responsibility from an early age, i.e. starting in primary school, when they are
most receptive to the adoption of healthy lifestyles and behaviour. It is also a
means of reducing social inequalities, in so far as it equips each child with the
same tools to prepare fir a healtity adult life. Further work should therefore fnq»$
on supporting efforts in Member States to devise and test school health education
programmes and a teacher-training programme. To this end, exchange? of
egqrerience and teadung materials should be encouraged, as should the
implementation and evaluation of plot education projects on the various risk
factors and health determinants (nutrition, alcohol, tobacco, drugs, physical
exercise, hygiene, etc.). These activities should involve dose cooperation not only
between the ministries involved (mainly education and health) but also between
all players in tire school community (parents, teachers and school administrators).
It would also be appropriate to involve non-governmental organizations which are
likely to be able to make a significant contribution towards promoting and supporting health education in schools, especially in those cremtries and rtynni
where infrastructures and activities are poorly devdoped. This initiative should be
accompanied tty rigorous evaluation of both tire application ofteaching afqrroaches
and the results achieved. In this way it will be possible to transfix tire most
conclusive experience acquired to other countries. These measures carried out in
tire context of tire horizontal programme on health promotion will be
complemented by specific measures on tire prevention of cancer, AIDS, drug
dependence and accidents.

83.

The workplace also represents a suitable setting for health education measures,
especially nutrition education in tire context of the works canteen. Other
possibilities indude prevention of alcohol and tobacco abuse, and education
relating to the identification of stress factors and prevention of excesrive ittres?

84.

Leisure, relaxation and snorts facilities (youth dubs, sodo-cultural centres, holiday
centres, sports dubs) can also provide settings for health education measures
aimed at addescents and young people who have left the school system, with the
emphasis on risk factors which are particularly critical for this age group
(sexuality and AIDS, drugs, tobacco, alcohol, road accidents, suicide, etc.).

85.

The programme objectives with regard to health education are to:

promote the inclusion of health education as part of Member States' school
curricula for all ages;

25

encourage cooperauon oeweeu nacmucx.(scho^k
of health education programmes tailored to differen>
-dolescents
SodTleiwre. etc.) »>d different urget groups <e.g chtldreo, .dolescents
and young adults, workers);

cnnnrt and disseminate the results Chest practices") of innovatory
experiments and demonstration projects concerning health education m
different contexts (school, work, leisure, etc.).
In th, light of these objectives the Comntissioo will support trfons in the
86.
following areas:

and disseminatiOT of school health education
geared to different ages and

„ , ,
Schools:

cooperation with WHO and the Council of Europe.
.

Worltp^gw^h^to^^J^^^
concq”?s

rf tenching materials, dissrsninahoo of
taov-orx eapeshherds, etc.

S^i^^gnnnmes addressing health and safety at work.

Leisure: health education experiments promoting posithre
behaviour among young PeoPj®“d
such as sport and
system (but are still without employment) m contexts surtias^onana
Ssure activities and sociocultural activity centres, innovatory means of

rdiirati an and information tedmology.
C

Vocational training in public health and health promotion

87.

respect of problems of particular concern in terms of public h

Health professionals in
88.

^tSSmatto0^

occupation, leisure) p!ay a key
community action can contribute to
education messages within the Community, vunimuu. ,
26

42
making health professionals more aware of the important contribution they can
make to the prevention of major diseases through information, education and
promotion measures. These measures will be implemented taking account of
experience acquired through the existing Community education and training
programmes including ERASMUS and COMETT and in coordination with the
proposed SOCRATES and LEONARDO DA VINCI programmes.

89.

In addition to health professonals, other professions are also involved in health
promotion, particularly social wtvkers, instructorsand teachers. Their effectiveness
in putting accross the messages of health promotion dqiends not only on the
quality of their expertise (both the content and the methodology of their activities)
but also on their knowledge of health promotion, information and education.

90.

Tn order to develop the "health promotion" qjproadi in Member States’ health
policies, the Community will encourage the inclusion of health promotion and
public health modules in training courses for health professionals and persons
reqxmsble for public health policies, emphasising interdisdplinaiy training.

91.

The objectives of the programme as regards training education will be to:

-

increny the awareness of health professionals of the active role they have
to play in health information, education and promotion;

-

encourage consideration of health aspects other than those traditionally
taught concerning the biological and medical aspects (i.e. social,
psychological and interdisciplinaiy aspects) in basic and in-service
professional training;

-

encourage cooperation between Member States and professional
associations concerning training in the prevention of disease and
dissemination ofinformation and exchanges of esqjerience between training
bodies in the Member States;

-

improve information on public health and health promotion training
available in the Community;
\

•

develop rnnrrfination between Member States in respect of the content of
public health and health promotion training courses.
92.

To help achieve these objectives, the Commission will support actions in the
following areas:

Survey of training bodies and available courses in the fields of public
health/ health promotion and health education and preparation of a
Pumpman directory. Comparative analysis and evaluation of training
courses. Dissemination of information and documentation on available
training Constitution of networks of Schools of Public Health, universities
and training bodies with a view to developing a common core in training
courses and student/staff exchanges.

27

FromOU on oi vouiunmuon ana

uciwcui ivA&***vrw<

subject of Public Health training course content as regards health
promotion, as well as training measures in public health and health
prcxnotion, aimed at professionals, administrators, and decision-makers,
emphasising interdisciplinary approaches.
Training activities concerning health education in schools aimed at
teadiers, instructors and other staff concerned and for the development of
modules, teaching aids and other materials for teachers and others involved
in health education; encouragement of cooperation between Member States
concerning training for health professionals in the prevention of disease,
die early detection of alcoholism and information for die public on sdfmedicadon.

D.

Specific prevention and health promotion activities

93.

Among die health determinants not covered by specific preventive measures under
disease-specific programmes such as on cancer, drugs and AIDS are tiiose which
- considered separately nr together- have a significant influence on public health.
These factors indude nutrition, risk-taking behaviour, hygiene and selfmedication. The Community will make an effort to contribute to specific
prevention and promotion activities in respect of these factors.

94.

Furdiermore, in order to achieve die objective of a high standard of health
protection, die Community will devote special attention to particularly vulnerable
or (fisadvantaged population groups (the poor and exduded, disabled, immigrants,
elderly, (fisadvantaged adolescents and young people), through prevention and
health promotion activities aimed specifically at such groups.

95.

The objectives are to:

96.

- •

improve knowledge of die situation and die problem of health promotion
in relation to certain health determinants and disadvantaged population
groups;

-

promote die exchange of experience and information between the bodies
in the various Member States concerned with these factors and population
groups;

-

support innovatory projects and experiments and transnational cooperation
in health promotion with regard to these factors and population groups.

The Commission will support actions in die following areas:
Integrated health promotion activities and projects relating to
yirtvantage^ or vulnerable groups and particular territorial areas
(depressed inner-city or peripheral areas, rural areas, etc.) and
incorporating die intersectoral dimension of health promotion
("comnumity-based approach*). Review of current projects in Member
States, assessment and dissemination of "positive experience*.

28

43

*

44

Surveys and analysis concerning different aspects of nutrition (socio
cultural and ethnic differences) in relation to major diseases, particularly
cardiovascular diseases, exchanges of experience and infonnation between
Member States and the bodies concerned. Analysis, evaluation and
exdumge of experience between Member States in respect of innovatory
measures for the prevention of cardiovascular and related diseases. The
establishment of a network of institutions and organizahous with expertise
iri-developing such measures

Cooperation between Member States on medication, including selfmedicatioQ, in cooperation with general practitioners and pharmacists;
analyses and surveys to establish the current situation, to monitor the
devdopment of these practices and to assess their implications.

E.
97.

Health promotion structure* and strategies

Development of the health promotion approach as an integral part of Member
States' health policies is bound to make a positive contribution towards
overcoming the difficulties caused by two sets of constraints which at first sight
seem to be conflicting, namely:
-

the commitment of the Member States and the Community to ensure a high
standard of health for the population,

-

dedaons and choices which have to be made with regard to health policy
and financing

98.

At the moment there are Curly sdistantial differences between Member States as
regards the level of development and implementation rf global health promotion
strategies Similarly, the structures and resources utilised differ significantly. The
Community, by promoting die exchange of experience and assessment of the
results of such policies, can contribute to die design of common strategies.

99.

On the basis of these principles, the objectives of Community actions are to.

-

encourage the development of a health promotion approach in Member
States' health policies;

-

promote consultation and coordination between Member States on various
aspects of health promotioi policy and on devising health promotion
strategies;

encourage cooperation, exchanges of experience and dissemination of
information on "good practices*.
100.

The Commissi cm will support actions in the following areas:

-

Surveys and comparative analyses of health pranotion structures and
strategies, and evaluation of policies. Exchanges of infonnation and
experience, specification of common objectives and stratums for health
promotion policies and structures.
29

Crretr networks of national or regional bodies responsible for health
promotion through an integrated approach fi.e. covering the various
determinants, contexts and population groups), with a view to die exchange
of informatinn and experience, dissemination of information on "good
practices* and implementation of joint activities and projects.

Activities ( surveys, analyses, seminars, expert groups, conferences ) with
a view to encouraging and supporting cooperation between Member States
on various strategic aspects of public health and health pranotion.

VJ

Other instruments of Community action

101.

Since Community action to promote health seeks to encourage a healthy lifestyle
and responsible conduct to safeguard health, and to help to create socio-economic
and environmental conditions which are conducive to health, it stands at the
crossroads of several policies.

102.

The Community, in addition to the action which it will take under Artide 129, has
at its disposal a wide range of legal and financial instruments deriving from other
Community polides, which can contribute to health promotion.

103.

Artide 129 of the Treaty, in its paragraph 4, provides for the adoption by Council
of incentive measures but it explidtiy exdudes hannonisaticn of the laws and
regulations of the Member States. The second indent of the same paragraph
provides that in order to contribute to the achievement of the objectives of health
protection and promotion, the Council may adopt recommendations on a proposal
from the Commisson. Thus if it becomes
following appropriate
consultation, that such action is needed and will attract support, the Commrsaon
may submit proposals for incentive measures or recommendations to the Council
based on this Artide on aspects of health promotion.

104.

In view of the intersectoral dimention of health promotion (socio-economic
conditions, physical environment, risk factors), instruments in policies other than
public health but which have an impact on health, e.g. foodstuffs, the
environment, safety, hazardous substances, working condition^ consumer
protection, etc., may also contribute to health promotion and protection.

105.

Artide 129 of the Treaty spedfically states that Health protection requirements
shall form a constituent part of the Community’s other polides". This provision
has two facets:
certain polides contribute directiy or indirectly to promoting health;
it must be ensured that the effects of these other policies are compatible
with the needs of health protection.

The principal policy areas having an impact on health are the following:

30

45

46
106.

Sflffial policy, both in general terms and insofar as it relates to certain specific
contexts, such as work, safety and health at work or certain social groups (the
disabled, migrants, the excluded, the poor, the elderly, etc ), is a vital instrument
for improving the basic social conditions which are essential to the health of a
group or community.

107.

Environmental policy, which has four objectives: preserving, protecting, and
improving the quality of the environment, protecting human health, prudent and
rational utilisation of natural resources and promoting measures at international
levd to deal with regional or worldwide environmental problem<t Last year the
Council approved a European Community programme of policy and action in
relation to tire environment and sustainable devdopment

108.

Regional policy and

109.

Agriculture and fisheries are relevant in terms of the supply of healthy and good
quality foodstuffs. In addition, the economic interests involved in agricultural
policy may impinge on the protection and promotion of health in areas such as
alcohol and tobacco consumption, eating habits and the types of foods produced
and promoted (animal/vegetable fats, fruit and v^etablesffibre).

110.

Health protection and personal safety are two of the main objectives of consumer
policy. Consumer policy is concerned with the quality and nature of foods and the
safety of objects and utensils used in day-to-day life. Industrial policy and internal
market policy also have a major part to play with regard to the quality of
foodstuffs, safety of products in daily use and the quality, safety, and efficacy of
pharmaceutical products.

tions bv the structural funds pursue the general
objectives of economic and social cohesion and are mainly directed towards
improving economic and social standards in the least prosperous regions and
areas. These instruments indirectly contribute to promoting health and ensuring
an overall improvement in sanitary and social conditions. This particularly applies
to action by the European Regional Devdopment Fund (ERDF) on water supply
and sewage treatment infrastructure or by the European Social Fund to assist the
unemployed.

Energy policy seeks to influence the levd and structure of production and use of
energy in order to promote economic growth and the wdl-bdng of the citizens.
The production and use of energy may have a negative impact on the
environment and may thus affect living conditions for the population. A strong
policy in favour of the rational and efficient use of energy may then have a
positive impact in the area of public health.
111.

Fiscal policy may also have a certain indirect influence on the consumption of
certain products which are risk factors (e.g. tobacco, alcohol). Among the aspects
to be talxn into account in transport policy are nuisances harmful to health (noise,
pollution) and safety considerations (e.g prevention of road accidents).

112.

Statistics and indicators relevant to health are an essential dement in health
promotion in providing up-to-date information and facilitating -evaluation, and if
necessary adjustment, of Community actions in this area (e.g. framework
programme for priority actions in the fidd of statistical information 1993 to
31

1997).
Pf^^Xion programme on health data and indicators,
will be consider^ n fir^e
P
its
to makc

47

individual aware
^tributing to health promotion, encouraging
gf yPllflK
and behave responsibly. Finally, the enormous
them to adopt heal y
an(j oomnnmication technologies can be
«pansi°'J *n nrdVtTir^m and edurate ie public, target groups >r health
pASAAA •heh»lt1,o«P««- AM- of*. Triages Apptarions

Programme and the CARE project ).
113.

SUS *. *-»««i"**-<doc,OTs’

,toisB’ ’ten“*dsB-

midwives).
114.

the speciac pragraiinte for taomettapemd
“".AUX for support to public hedtb resesrdt w conneOtoo wth e«un
AsZU promotioo (etlucBioo. preveotioo. strstqpe ptammg. onpuuzrmoo
of care systems, etc.).
115

In order to ensure that health considerations are in fact taken into account in other
community polici« tmd tocoordiMt.^uvities wth .to sttout.tg.lug
standard of health protection and promotion, the Commisso^ in its
SLunication of 24 November 1993, set out the following arrangements.

the interdepartmental consultation procedure prior to Commission derisions
is to be usedwhenever a decision may have implications for public health,
mi Interservice Group on Health was set up to ensure reciprocal information

and coordinatioXth regard to health and the health aspects of other
policies;
in its annual report to the Council, the Commission will provide full
information on the health implications of other policies.

V4

Cooperation with international organization! and third countrie*

116.
terms of Article 228 (conclusion of agreements). Article 229 (relations with UN
nrrrans soecialised agencies and other international organizations). Article 230
(Sc.^EuropO ^d Article 231 (Organization for Economic Cooperation and

Development).
32

48
International organizations

117.

Cooperation with the WHO as described in Chapter 1 of the Commission
Communication on CEC-WHO collaboration07’ in the field of prevention, health
prrwnnrinn and education will be continued. A number of WHO programmes are
related to the health determinants addressed by this proposed programme. The
Commission will consider which of these might usefully be the subject of
cooperation and discuss possibilities with the WHO. The most appropriate
programmes for cooperation are concerned with lifestyles conducive to health but
aspects of programmes for reducing communicable diseases, suicide and
urririMits, for controlling cancer and for improving the health of elderly people,
mental health and family health, could also be relevant In addition, the WHO,
with its world-wide remit and regional offices, is well placed to cooperate in work
with third countries. The Commission will consult with the WHO on the most
effective means of associating work in such countries with activities under the
present programme and on possibilities for cooperation with the WHO in this area.

118

The main activities of the Council ofEurope of relevance to this programme are
those concerning the role of prevention and health education (especially work with
teadiers, curricula and health education in schools, on which the Council, the EC
and WHO are cooperating in a joint project), and measures concerning alcohol,
drag addiction (including those of the Pompidou Group) and AIDS. A recent
relevant prefect concerns health care for institutionalised persons (including
prisoners). These activities will be the object of continuous consultation with a
view to strengthening cooperation.

119.

The special contribution of the Organixation Jar Economic Cooperation and
Development (OECD) in the health sector relates to the economic aspects of
health systems and costs in a wide range of countries with devdoped economies,
including Member States. The particular aspects of this work which could be the
subject of cooperation under the proposed health promotion programme concern
comparative trends in health statistics on preventable diseases and estimates of the
economic costs of the various health risk factors which the programme aims to
reduce. OECD experience and information on related health problems, systems
and approaches in devdoped countries outride Europe could also be of interest

120.

Other UN organizations and agencies also do work rdevant to health promotion.
Important among these are the UN Educational, Scientific and Cultural
Organiratinn (UhjESCO) and the UN Children's Fund (UNICEF). An example of
activities of interest to the present- programme is the current joint project of
UNESCO and the UN Interregional Crime and Justice Research Institute
(UNICRI) on the role of women in preventive education against drag abuse in the
Mediterranean region. This project is concerned with the influence of women in
the family, at school and in the local community. The International OrganizaUon
for Migration (IOM) also has interests in health promotion among immigrant

an

Coaununication from the Commission on collaboration between the
Commission of the European Communities and the World Health
Organization (COM(93) 224 final of 24 May 1993).

33

minority groups, which could provide opportumues 1U1 VK/V’fr'
Community action under the present programme targeted on such groups.

Third countries

121.

USA, Australia and New Zealand.

Cooperation with third countries wiU take into accoum^pres^a^ to 1^
between these countries and the Community. In the framework rfthe E^A
Agreement collaboration on public health could be envisa^i Fdowmg the
cSdSon of the European Council of Copenhagen (1993) Community
programmes should be opened up to the countries of Central and Eastern Europe
having association agreements with the Community.
VL

CONSULTATION AND PARTICIPATION
A.

122.

In order to permit die fullest possible integration of the activities of the
partners foreseen in the programme, induding scientific expertise at the faintest
level and the national authorities, the Commission will propose the creation of an
Advisory Committee chaired by the Commission comprising representatives o
each Member State. The composition of the committee should enwe adequMe
representation of the interests and expertise of the national
professionals and the non-governmental organizations in the field of heal
promotion.
B.

123.

Advisory bodies on health promotion

Other groups involved

The Commission intends to ensure dose involvement of costing ffirtiomi
coordination institutions acting in the field of health promotron
enhance the motivation and involvement of the national players. Where su
institutions do not already exist, the Commission will “co^
establishment Acting as the national counterpart to the Comnussion, to
institutions will have to help the many different organizations and P”^®0115
involved to work more dosdy together at the national and Community level.

34

49

50
124.

Several non-governmental organizations. (European Public Health Alliance,
Association of Schools of Public Health in the European Region, European Public
Health Association, International Union for Health Promotion and Education, etc.)
are active in the daboration, formulation and monitoring of health promotion and
public health policy at Community levd. In view of the role played by these
organizations, the Commission will maintain and strengthen its links with them,
both thrnugh the Advisory Committee described above and through direct links,
in particular in establishing networks.

125.

The very wide scope of health promotion activities and the multi-faceted links
with other a^>ects of public health or other policies and sectors require that the
Canmisson should respond with flexibility to the need to involve different types
of partners. The Commission will ensure coordination of activities under this
programme and under the programmes referred to in the Commission
communication on a framework for public health, and also other relevant
Community policies.

VIL EVALUATION AND REPORTS
126.

The evaluation and reporting arrangements of the action programme will comprise
two key dements:
an indq>endent peer review of the major activities supported;

an overall report on actions undertaken under the programme, to be
submitted to the relevant Community Institutions by the Commission half
way through programme, and a final report at the end of the programme.
127.

Independent peer review of the major activities supported. Evaluations of the
antivitirt supported by the programme would make it easier to transfer project
results from one Member State to another and hence increase the Community
aririrri value of the programme. To ensure that such evaluations are effective, the
Commission may consult national authorities and other experts in the field in
order to establish appropriate criteria and procedures.

128.

Overall reports on the programme: These rqxxts will allow the Council and the
European Parliament to assess whether any adaptation in the programme's
approach or budget would be appropriate.

129.

General informatim activities: The Commission will ensure that the results of the
most significant activities and evaluations are made available to interested parties
and the general public.

35

51

Proposal for a
mijRijPEAN PART JAMENT ANDJ

-top** . pr^-e of

*«“■ •“

DE<WKI
P"-*”*-

eduction nnd training within the framework for action

in the field of public health

36

5

52
EXPLANATORY MEMORANDUM

1.

In its Communication of 24 November 1993 on the framework for action in the field
of public health, the Commission defined a framework for future Community action in
order to attain the objectives on health protection laid down in Artides 3(o) and 129
of the Treaty establishing the European Community. The role o£ the Conmunity is
identified as underpinning tire efforts of the Member States in the public health field,
assisting in the formulation and implementation of objectives and strat^jes, and
contributing to the provision of health protection across the Community, setting as a
target the best results already obtained in a given area anywhere in the Community.
Community action is directed to the prevention of diseases and the provision of health
information and education. Health protection requirements must also be part of other
Community policies.

2.

In its Resolution of 27 May 1993 on future action in the field of public health, the
Council stated that one of the basic objectives is the "promotion of healthy lifestyles
and a healthy physical and social environment". This objective specifically indudes
health promotion activities. At the same time the Council asked the Commission to
submit proposals for priority measures in this field.

3.

The European Parliament adopted, on 19 November 1993, a Resolution on public
health policy after Maastricht, calling upon the Commission to develop and implement
activities on health education and health promotion, prevention of drug dependence and
accident prevention, taking into account the problems of the elderly and cardiovascular
disease. The Resolution of the European Parliament, adopted on 17 December 1993,
on health education in schools, highlights the importan ce of health education, and states
that there is a need to provide suffident human and financial resources to develop
heath education policies at Community level.

4.

Future Community action in the public health field must take into account the principle
of subsidiarity and the requirement of proportionality. It is worth noting in this context,
that the diversity observed within and between the Member States in respect of
geography, dimate, lifestyles, culture, socio-economic conditions and the environment
is such that generally speaking, no detailed requirements can be proposed by the
Community. Activities must be sdected on the basis of prior appraisal and should yidd
a Community added value while achieving maximum cost effidency.

5.

On the basis of an examination of the main causes of mortality and morbidity induding
an analysts of the main health determinants or risks implicated in these causes, together
with the most effident means of dealing with these problems at Community levd, the
Commisrion identified the priority areas for possible proposals for multiannual action
programmes Future strategy will be based on the one hand on general measures
concerning health promotion, information, education and training, and health data and
indicators, and on the other hand on action spedfic to certain diseases or other major
health scourges. It is worth noting that measures aimed at providing health promotion,
namely health information and education, have, been spedfically identified in
Artide 129 of the Treaty for Community action in the fidd of public health.

37

The present proposal concerns a programme for general health promotion measures to
be undertaken in the Community. Health promotion activities (including in particular
health information, health education and training for professionals) constitute a major
element in current health policies and strategies

6.

The health of an individual can be characterized by three sets of factors:

7.

endogenous factors which are inherent to each individual, and which are the
result of genetic heritage and anatomical and physiological characteristics;

behavioural factors in which health determinants play an important role and
which are under the control of the individual (nutrition, alcohol, tobacco,
physical exercise, drugs, etc.), all of which may be influenced by societal
factors, culture, education, training and information;
environmental factors and socio-economic conditions, which are related to the
community in which the individual both lives and works.
8.

The state of health of a community depends to a certain extent upon the prevailing
physical environment and socio-economic conditions. Within the Community, where
the overall health level is among the best in the world, there are differences in life
expectancy, mortality and morbidity between groups related to differing socio-economic
status. The main social and environmental conditions which are of decisive importance
for health are housing and urban planning, quality and level of education, employment
and working conditions. Improvement of the overall health level in Europe must take
account of the unfavourable conditions of certain groups (the excluded, poor, elderly,
and immigrants) and communities (inner-dty and peripheral areas, rural areas, etc ),
either because they are more exposed or more sensitive to certain risk factors, or
because thrir sodo-economic conditions are unfavourable, or because their behaviour
and lifestyles make them more vulnerable.

9.

The primary focus of health promotion must be health-oriented rather than diseaseoriented. It does not concern itself with care, treatment and physical assistance but, if
carried out effectively, it can lead to a reduction in the costs of treatment and care. All
Member States are concerned with containing the costs of treatment and care, and in
its Communication of 24 November 1993, the Commission described the challenges
facing them: an ageing population, increasing population mobility, changes in lifestyle
and working conditions, growing health demands on the part of citizens, and socio
economic problems. In this context, the ’health promotion" approach, which invests in
health so as to reduce the costs of care and treatment will help to contain costs and
thus help the Member States to provide a high standard of health for the population.

10.

The overall aims of health promotion in the European Union both at European
Community and Member State level may be •summarized as follows:

-

to promote and support the provirion of information and education on healthy
lifestyle, in particular balanced nutrition, appropriate physical activity, safe
sexual bdiaviour and, positive health behaviour such as the avoidance of
smoking and addictive drugs, moderate drinking and sensible ways of reducing
and coping with stress;
38

54
to improve the standard of health of all European citizens, and in particular
disadvantaged population groups;
to provide individuals with the information and knowledge needed to take
action against the occurence of disease, accidents and injuries;

to allow citizens to take action so as to develop and use their full health
potential in order to improve their quality of life.
11

The action programme on health promotion lays emphasis on activities already
identified in the Commission’s Communication on the framework for action in the field
of public health : information on health, health education in dififerent settings and
particularly at school and at work, vocational training measures tailored to health
professionals involved in health promotion and prevention, encouragement to
cooperation between Member States as regards health promotion policies, strategies and
ctnirftrrrc Other priorities identified are prevention and promotion measures concerning
key dements of public health (e.g. nutrition and cardiovascular diseases) which are not
specifically dealt with in the action programmes concerning qwcific diseases or
scourges, such as cancer, drugs, and AIDS and other communicable diseases.

12.

The Commisson’s role will be to encourage and facilitate exchanges of information,
experience and models of good practise as well as to support and coordinate, as
necessary, activities at Community level. The Commission will, in particular, siqiport
proposals’ submitted by Member States and initiatives involving organizations and
agencies active in the field of health promotion. Cooperation with international
organizations and transnational associations active in this area will also be fostered.

13.

The devdopment of health promotion measures and in particular health information,
education and training directed at lifestyle factors and individual behaviour, must also
take account of environmental and socio-economic conditions of the community in
question. It follows that a range of policies may also contribute to achieving the aims
of health promotion, as is Set out in Artide 129 which states that health protection
requirements shall form a constituent part of the Community's other policies.

14.

The Commission will transmit a mid-term report and a final report on the
implementation rtf' the programme to the Council, the European Parliament, the
Economic and Social Committee and the Committee of the Regions. This will enable
them to assess the progress of the work and the effectiveness of the actions taken.

39

55

Proposal for a
FITROPF-AN PARLIAMENT AND COT WH PECISIQH

in the field of public health

THE EUROPEAN PARLIAMENT AND THE COUNCIL OF THE EUROPEAN UNION.
Hmng

Io the Ttoly esteblishieg the European Comrowuty, end in particular Article 129

thereof.
Having regard to the proposal from the Commission™,
Having regard to the opinion of the Economic and Social Committee™,

Having regard to die opinion of die Committee of the Regions™,

Whet® the Commission, in its Commtmicmioo rf 24 Ncotmibg 19SD a.

education and training;

Coimal, of 23 November WB»,concOTu^
^stances and medicines, drug abuse,
ZSn^e^S^iXrt^ imnnEd effect mr hmldu
in nund the re!^
problems of safety and accident prevention;
Wherem. the Rmoludo. of the Council .d
Member States, meeting within the

healtiiv lifestyle rdated to nutntiou

nutrition in keeping with individual needs;

(1>

m
o>

OJ No
OJNo

<«>

OJNo ’
COM(93) 559 final.

w

OJ No C 3, 5.1.1989, p. 1.
OJ No C 329, 31.12.1990, p. 1.
40

56
Whereas the Conclusions of the Council and the Ministers for Health of the Member States,
meeting within the Council, of 13 November 1992, concerning health education^ based on the
Commission Communication to the Council of 11 May 1992 on school health education'”,
identified the school as a vital setting for systematically developing a healthy lifestyle that will
muhle sickness and accidents to be reduced, considered that there were a variety of other settings
such as homes, local communities, workplaces, hospitals, etc. in which health promotion and
health education had a central role, and invited the Commission to strengthen cooperation
between Member States in implementing effective health promotion and health education actions
in the various settings;
Whereas these actions need to be undertaken within the framework for action in the field of
public health set out by the Commission'4’ and take into account, as the Council requested in its
resolution of 27 May 1993w, other action undertaken by the Community in the field of public
health or which have an impact on public health;
Whereas in its Resolution00’ concerning public health, health promotion and health education the
European Parliament formulated a series of proposals for Commimity action in the field of
accident prevention and prevention of cardiovascular diseases which are not fee subject of
existing Community programmes;

Whereas the results of the integrated approach as demonstrated in the joint World Health
Organization - Council of Europe - European Community Project "The European Network of
Health Promoting Schools* are encouraging with respect to ways of implementing health
promotion in particular settings;
Whereas it is recognized that socio-economic conditions such as housing, unemployment,
urbanization, and social exclusion should be taken into consideration in the promotion of health,
particularly for those living in deprived areas;

Whereas health education and information are expressly mentioned in the provisions of the Treaty
dealing with public health, and constitute a priority for Community action in public health;
Whereas, in accordance with the principle of subsidiarity, action on matters not under the
exclusive competence of the Community, such as those on health promotion, must be undertaken
by the Community solely where, by reason of their scale or effects, the objectives can better be
achieved at Community level;

Whereas cooperation with the competent international organizations and with non-member
countries should be strengthened;
Whereas a multiannual programme should be launched with clear objectives for Community
action, and priority action selected to promote the health of all the citizens of the Commumty as
well as appropriate mechanisms for the evaluation of such action;

<*)

w
(10)

OJ No C 326, 11.12.1992, p. 2.
SEC(92) 476 final.
OJ No C 174, 25.6.1993, p. 1.
PE 205-804 final.
41

57
Whereas the programme has to contribute to the enhancement of awareness of health
detenninanis and risk factors, early detection of adverse effects, counselling and advice, and
health and social support;
Whereas, from the operational point of view, the investment made in the past both in terms of
the establishment of Community networks of non-governmental organizations and of the
mobilization of all those involved in health promotion and education has to be safeguarded and
devdoped;
Whereas, however, posable duplication of effort has to be avoided by the promotion of the
exchange of experience and by the joint development rf basic information modules for the
public, for health education and for training members of the health professions;

Whereas this programme must be of five-year duration in order to allow sufficient time for
actions to be implemented to achieve the objectives set.

HAVE DECIDED AS FOLLOWS:
Article 1

A Community action programme on health promotion, information, education and training is
adopted for a five-year period, from 1 January 1995 to 31 December 1999.
Article 2
The Commission shaft ensure implementation of the actions set out in the Annex in accordance
with Article 5 and in dose cooperation with the Member States and the institutions and
organizations active in health promotion.

Article 3
The budgetary authority shaft determine the appropriations available for each financial year.

Artide 4
The Commission shall ensure that there is consistency and comptoentarity b*™*®
Community actions to be implemented under this programme and the other relevant Community
programmes and initiatives.

Article 5
1.

For the implememaioo of this
the CoramsMO shsll
committee of an advisory nature, hereinafter referred to as The Committee comP?^
of two representatives ftum each Member State and chaired by the representative of the
Commission.

42

58
2.

The representative of the Commission shall submit to the Committee a draft of the
measures to be taken. The Committee shall deliver its opinion on the draft, within a time
limit which the chairman may lay down according to the urgency of the matter, if
necessary by taking a vote.
The opinion shall be recorded in the minutes; in addition, each Member State shall have
the right to'ask to have its position recorded in the minutes
The Commission shall take the utmost account of tire opinion delivered by tire Committee.
It shall inform the- Committee of the manner in which its opinion has been taken into
account

Article 6
1.

The Community shall encourage cooperation with non-member countries and with
international public health organizations, including tire World Health Organization.

2.

The EFTA countries, in tire framework of the Agreement on the European Economic Area
and tire countries from Central and Eastern Europe with whom tire Community has
concluded association agreements may be awriafri with the activities described in the
Annex.

Article 7
1.

The Commission shall regularly publish information on tire actions undertaken and the
possibilities for Community support in tire various fields of action.

2.

The Commission shall submit to the European Parliament, tire Council, the Economic and
Social Committee and the Committal of tfae Regions a mid-term report on the actions
undertaken, as well as an overall report at the end of the programme.

Done al Brussels,
For the European Parliament
The Presdent

For the Council
The President

43

ANNEX

COMMUNITY ACTION PROGRAMME ON HEALTH PROMOTION

(1995-1999)

HEALTH INFORMATION

1.

Efforts to contribute to a better knowiedge of the psydio-sodological mechanisms
involved and of health information methods and techniques, as well as fostering the
assessment of results.

2.

Surveys of public opinion on various aspects ofhealth promotion (Eurobarometer survey)
and support for the preparation and assesment of specific information campaigns
including those coordinated at Community level or in several Member States. •

3.

Support for a Fitmpwm infrastructure for information and documematioo on public
health and health promotion for use by professionals, administrators and dearion-mates
in die field of public health, and dissemination to interested parties of information on the
Community** activities in tins field.
Health educatkw

4.

5.

6

Promotitm, by consultation between the Member States, of the indurion of health
education in school curricula and support for the devdopment and distribution of
appropriate health education programmes, teadung materials, and modules. Support for
demrmstration projects and innovative measures with the aim of promoting healthy
lifestyles and behaviour, induding support for the European Network of Health
Promoting Schools in cooperation with WHO and foe Council of Europe.
Support for health education measures in the workplace, particularly in relation to
prevention of alcohol abuse and tobacco consumption, and nutrition.
Support for health education projects among young persons and adolescents who have
left foe school system in settings such as sport and leisure activities and 8OO^a“tu™
activity centres, induding innovative means of providing continuing structured health
education. •

44

60
C.

NOCKTV&UAs TRAINING IN PUBLIC HEALTH^AfTD HEALTH PROMOTION

7.

Review and assessment of existing structures and gaining schemes in public health and
health promotion and compilation of a European directory. Support for cooperation
involving Schools of Publid
Publ Health, universities and bodies providing training in this
area with a view to the d lopment ofxCxnmon training courses and exchanges of
students and teaching staff

8.

Promotion of cooperation between the Member States on the content of training courses
and tmining activities in the fields of public health and health promotion for
prnfe<wi finals, administrators, managers and dedsion-malcers, emphasising
interdisciplinary approaches.

9.

Support for training activities concerning health education in schools aimed at teachers,
instructors and other staff concerned including development of modules, teaching aids
and materials Support for training for health professionals in the prevention of diseases,
early detection rtf'alcoholism and information for the public on the use of medicines and
sdf-medication.

D. Specific prevention and health promotion measures

10. Support for migrated health promotion activities and projects relating to disadvantaged
or vulnerable groups and particular territorial areas, and incorporating the intersectoral
dimenMon of health promotion.
11. Examination of the role of balanced nutrition as a health protection measure and of
nutrition in the etiology of diseases, particularly cardiovascular diseases. Promotion of
analysis, evaluation and cxdumge of experience in respect of innovative measures for
tire prevyntinn of cardiovascular and related diseases.
12. Support for activities on medication, including self-medication, in cooperation with
general practitioner and pharmacists, as well as efforts to monitor the development of
practices and assess their implications.
F

HEALTH promotion strategies and structures

13. Surveys and comparative analyses of health -promotion structures and Strategies and
assessment of these policies, as well as activities to encourage and support cooperation
Member states on various strategic aspects of public health and health
promotion.
14. Support for networks of national or regional health promotion bodies, adopting an
integrated approach (i.e. an approach covering tire various determinants, contexts and
population groups) and promotion of joint activities and projects.

45

*

61

*

FINANCIAL STATEMENT

1

\

THUE OF OPERATION

Community action programme on health promotion, information, education and training
in the field of public health.
2

BUDGET HEADING INVOLVED

B3-4302
3

. Legal basis

C^d^SIX^f 27 W^^Xure^nta Ae fiddof pubhe heakh

Commission communication (COM(93) 559 final of 24 November 1993) on the
framework for action in the field of public health.
4

Description of operation

4.1

General objective

To contribute to achieving the objectives laid down by the Treaty:

• under Article 3 (o\ the Community is required to make a contribution to the
attainment of a high level of health protection;
th*
Article 129 requires the Community to encourage
Member States and to lend support to their action. Community ac^°nJ® to be
directed towards the prevention of diseases, in particular major health scourges,
including drug dependence, by promoting research into their causes
transmissian, as well as health information and education.

Specific objectives of the programme

various collwive holth doermin^ (housmg. phys.ed
environment, education and health systems, woriang am.
Policies bv
encourage the "health promotion" approach m Member Statcs
lending support to various types of cooperation (exchanges of expen
,p
projects, networks, etc.).
46

62

4J,

Period covered and arrangements for renewal or extension

Five years (1995-1999)
Rrpcrt to be transmitted to the Council and European Parliament during die diird
year of die programme: any modifications necessary
Report to the Council and European Parliament at the end c£ the programme:
renewal or adaptation procedures.
5

Classification or expendituiue or revenue

Non-compulsory expenditure
Differentiated appropriations
6

Type of expenditure

Subsides towards die cost of projects carried out by public, semi-public or private bodies,
not crowding a certain percentage of the total cost of such projects.
7

Financial impact

7.1

Method of calculating total cost of operation

As most of the measures are new, the cost has been estimated on the basis of similar and
prqiaraiory measures carried out in 1994 under heading B3-4300 - "Improving public
health" (commitment appropriations: ECU 3.8 million).

A total amount of ECU 35 million for die period 1995-1999 would appear
necessary for these activities. The programme will gradually gain momentum
between 1995 and 1997 to reach a "cruising speed* for the last two years.
7.2

Itemised breakdown of cost

The proposed allocation of resources to this programme, as set out in die following table,
averages ECU 7 million per year for the period 1995-1999. The breakdown by action area
for 1995 is given for infonnadon. The indicative amounts for the following years will
have to be confirmed in conjunction with the successive preliminary draft budgets.

47

*

63

ACTION AKEA

K3B1995

19N

1997

1991

1999

TOTAL
199S-1999

<3

7

TJ

S

39

Mpi
icumo

UM>

B. HulB iifaritfn

L0O

C TnMiag far M
pMcWOMk

UMO

H SRdftc pranota taA pmMM

0990

t HMfH

0990

«

0390
mMob

TOTAL ME ■■ITU)

<

33

(1)
(2)

New programme in 1995-1999 and different breakdown compared with 1994
For die years 1996-1999 the indicative breakdown of appnqniations will not be
established until the budget authority has deeded the appropriations available for
each financial year. -

73

Schedule of appropriations

Cot mt

nt appropriations

1995

1996

1997

1998

1999

6

7

8

83

9

TOTAL
383

Payment appropriations
50%

1995

3.0

35%

1996

XI

32

15%

1997

0.9

23

33

1.0

23

3.7

1.0

23

4

7.6

13

4

53

73

8

35.0

1998

3.0

1999

53

Subsequent yean

TOTAL

6

63

48

7

6.7

73

r

64

s

FRAUD PREVENTION MEASURES; RESULTS OF MEASURES TAKEN

The grant application forms will require information on the identity and nature of
potential beneficiaries so that their rdiability can be assessed in advance.

Fraud prevention measures (checks, intermediate reports, final rqxxt) are included in the
agreements or contracts between the Commission and beneficiaries. The Commission will
check reports and ensure that work has been properly carried out before intermediate and
final payments are made.
In addition, spot checks are carried out by the Commission to verify how funds have been
used.
9

Elements of cost-effectiveness analysis

9.1

Specific objectives; target population

The Community measures are intended to ensure a high level of health for Europeans.
The action programme is situated a stq> ahead of the system of providing care and
treatment for die sick It is designed to prevent diseases and promote health by
devdoping citizens' knowledge of risk factors and positive attitudes and behaviour in
respect of health determinants such as alcohol consumption and nutrition, not forgetting
smoking, drugs, physical exercise, hygiene and sexual bdiaviour.

On the basis of the principle "prevention is better than cure", this approach is likely to
generate considerable savings in the overall cost of health systems.
The spedfic objectives and target populations are described for each of the main action
areas of the programme.
A.

Health information

Article 129 of the Treaty refers specifically to health information as a means of action.
The specific objectives of such action will be to:
»)

improve information for the public on health factors (risks and determinants) as
a fully-fledged instrument ofMember States' health policies (effective information
methods, evaluation of measures);

b)

support Community-level information campaigns on certain risks (e.g. alcohol
abuse) not covered by specific Community measures (cancer, drugs and AIDS
programmes);
49

00

c)

set up a Community information infrastructure in the field of public health and
health promotion (in-the form of a network) for public health professonals,
researchers and administrators.

Tamt •^•1 ilatiofr.

B.

b) depends on risk factor iu question (e.g. young pe<q)le/alcohd,
alcohol at work, etc.);
a,c) decision-makers, administrators and professonals concerned
with public health and health promotion measures.

Health education

Health education is specifically referred to in Article 129 of the Treaty as a means of
Community action.
The specf/?g objective of such action is to heighten individuals' awareness of the fact that
their health first and foremost depends on themselves and their attitudes towards health
risks and/or determinants (alcohol, smoking, nutrition, physical exercise, sexual behaviour
and hygiene, drugs, accidents, etc.). The aim is to encourage positive attitudes and healthy
lifestyles in all aspects of life (work, family, school, leisure), particularly among children
and young people.

Tamt population:

- children (school education)
- young people and adolescents (education in sport and leisure
activities)
- workers (health education at the workplace).

The intermediaries are teachers, instructors, parents and health professionals.

C

Thuning in public health and health promotion

l
The specific M
objective
is to develop, among health professionals (medical and para
medical staff), decision-makers and administrators, responsible for health policies or
measures, and the kqr players in health promotion (e.g. teachers, social workers),
knowledge, concepts and methods relating to public health, prevention, health prmnotion,
health information and health education.

Tamt population: health professionals, administrators and others responsible for public
health policies and health promotion measures.
The principal intermediaries and beneficiaries of financing will be public health colleges,
national health promotion bodies and universities.
D.

Specific prevention and health promotion activities

The specific objectives of this category of measures are health information, healtii
educaticm and prevention for certain particularly vulnerable or disadvantaged target groups
such as the poor, excluded, disabled, immigrants, elderly, and underprivileged adolescents
and young people.
50

•>

66

Tarrft papulation: aforementioned vulnerable or disadvantaged population groups.

Cooperation with regard to health promotion structures and strategies
The specitic objective of these measures will be to promote consultation between Member
States with regard to their health promotion structures and strategies by encouraging
erehanges of information and experience and the dissemination of information on "best
practices*.
Target population:

92

decision-makers and bodies responsible for health
promotion at national and regional level
persons responsible for implementation of health promotion
strategies
universities and collies of public health.

Grounds for the operation

Generally speaking, health promotion measures represent a modest proportion of Member
States' overall spending on health, although such measures could generate substantial
savings in the cost of looking after and providing treatment for the rick and victims of
accidents.
Similarly, the degree of priority given to health education in the school programmes of
the Member States varies considerably, and teachers are given little training in how to
play their health education role.

A substantial Community added value can therefore be realised by:
disseminating know-how and experience through cooperation and networking;
supporting pilot and innovatory experiments which bodies or associations cannot
cany out on their own (sharing of innovation risk);
training those involved in and responsible for public health and health promotion
policies.

The measures planned do not encroach upon the authority of the Member States, but
supplement their activities in the fields concerned (subsidiarity), focusing on subjects
where Community assstance can provide a genuine added value:

cooperation between Member States to define strategies and exchange esqterience,
transnational networks of bodies involved in promotion, education and training,
support for innovatory projects.
The choice of aid in the form of a subsidy is justified by the fact that beneficiaries are
public bodies or associations which do not generate income (other than allocations from
the State, contributions, donations or subsidies).

51

67
93

Monitoring and evaluation of the operation

-

Performance indicators

In implementing the programme, perfonnance indicators (initial objectives/results)
apprqxriate to the type of measure will be applied, e.g.
•

•
•
•
•
•
•
•

number of prefects and partners participating in international health promotion
measures,
number of studies of Community interest and number of publications,
number of networks established and number of participants,
number of schools participating in networks of health promoting schools,
number of training measures and trainees,
number of seminars and conferences and number of participants,
number of persons (target groups) readied by infonnatiOT and education measures,
number of training modules developed and extent of dissemination.
Details andfrequency ofplanned evaluations

Hach individual project should indude an evaluation sheet (results obtained
compared with initial objectives) adapted to die type of measure.
Fadi major action area under the programme can be die subject of an independent
evaluation during die course of the programme.
A programme implementation report will be submitted to the Council and
Parliament in 1997.
9.4

Coherence with financial programming

—

Is the operation incorporated in the DG'sfinancial programmingfor the relevant
years? Yes

-

To ’which broader objectives defined in the DG’sfinancial programming does the
objective of the proposed operation correspond^?
"To contribute towards ensuring a high level of human health protection" • Artide
129 of die Treaty.

10

Administrative EXPENDrruRE (Part A or the budget)

The new action programme referred to in this fmandal statement comes undo* the new
responsibilities of the Community in the field of public health following entry into force
of the Maastricht Treaty (Artide 129).

In addition to the staff currently carrying out similar and preparatory work,
implementation of the programme will necessitate the following additional staff:
1 grade A official, 1 grade B offidal and 1 grade C offidal - subject to the outcome of
the 1995 budget procedure and the Commission Decision on die allocation of funds.

52

68

^rKn1fWiH8-m7tin^ld I4s?ons
P,anned for 1995 in conjunction with the
hunching and implementation of the new action programme:
Meetings: :

2 meetings of the Advisory Committee (2 representatiives per Member State)
(2 x 24 x 658 - 31 584)
32 000
4 meetings of experts
(4 x 6 x 658 - 15 752)
16 000

(Conferences and seminars for presentaticm and implementation)
4 x 48 x 658 - 126 330
126 000
Total meetings: ECU174 000
Missons:

Luxembourg-Brussels (5 missions per month)
(60 x 200 - 12 000)
Other missions (Member States)
(25 x 1 000 - 25 000)

Total missions: ECU 37 000

53

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