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Models of health promotion

The kinds of health promotion programmes that students and schools implement reflect the health education models on which they are based. There are three main categories in which health education models can be broadly placed:

  • behavioural change model
  • self-empowerment model
  • collective action model.

(For more information about these models, see 'Characteristics of the health promotion and health education models'. Refer also to Nutbeam, 2000; Colquhoun, Goltz, and Sheehan, 1997; and French and Adams, 1986.)

While the three models are not mutually exclusive (many teachers and health professionals use all of them to some extent),  Health and Physical Education in the New Zealand Curriculum (1999) (PDF, 688 KB) focuses on the self-empowerment and collective action models.

Teachers' notes

Knowledge and understanding of health promotion is essential content for students studying health education at level 8 of the curriculum, and is required for students preparing for assessment against NCEA level 3 achievement standards and the Scholarship standard.

Physical education and home economics teachers need to understand the processes and the theoretical origins of health promotion so that they can apply these processes in their teaching and learning programmes without making health promotion a specific content focus for their students.

Behavioural change model

The behavioural change model came into use before the other two approaches. Many early New Zealand health campaigns were based on this model, and it is still widely used, in conjunction with other models, as part of comprehensive health campaigns.

The behavioural change model is a preventive approach and focuses on lifestyle behaviours that impact on health. It seeks to persuade individuals to adopt healthy lifestyle behaviours, to use preventive health services, and to take responsibility for their own health. It promotes a 'medicalised' view of health that may be characterised by a tendency to 'blame the victim'. The behavioural change model is based on the belief that providing people with information will change their beliefs, attitudes, and behaviours. This model has been shown to be ineffective in many cases because it ignores the factors in the social environment that affect health, including social, economic, cultural, and political factors.

Self-empowerment model

This approach (also known as the self-actualisation model) seeks to develop the individual's ability to control their own health status as far as possible within their environment. The model focuses on enhancing an individual's sense of personal identity and self-worth and on the development of 'life skills', including decision-making and problem-solving skills, so that the individual will be willing and able to take control of their own life. People are encouraged to engage in critical thinking and critical action at an individual level. This model, while often successful for individuals, is not targeted at population groups and is unlikely to affect social norms.

Collective action model

This is a socio-ecological approach that takes account of the interrelationship between the individual and the environment. It is based on the view that health is determined largely by factors that operate outside the control of individuals. (See the information about determinants of health in the Appendix.)

This model encompasses ideas of community empowerment, which requires people individually and collectively to acquire the knowledge, understanding, skills, and commitment to improve the societal structures that have such a powerful influence on people's health status. It engages people in critical thinking in order to improve their understanding of the factors affecting individual and community well-being. It also engages them in critical action that can contribute to positive change at a collective level.

Given the importance of determinants of health, the use of a collective action model is more likely to achieve healthy outcomes, both for individuals and for groups within society.

Health promotion and the Ottawa Charter

The Ottawa Charter for Health Promotion (WHO, 1986) provided much of the impetus for the change to using a socio-ecological approach for health education and health promotion. This charter recognised that major health gains were linked not so much to advances in medical knowledge as to increases in wages and living standards and to public health initiatives accompanied by policy changes at government and community levels.

The Ottawa Charter identifies nine broad prerequisites for health:

  • peace
  • education
  • food
  • shelter
  • income
  • a stable ecosystem
  • sustainable resources
  • social justice
  • equity.

It advocates "a socio-ecological approach to improve health in which people and their environments are considered to be inextricably linked" (WHO, 1986, page 3).

In relation to health promotion, the Ottawa Charter determined that five key strategies were needed to enhance public health:

  • creation of supportive environments
  • development of personal skills
  • strengthening of community action
  • building of healthy public policies
  • reorientation of health services.

A translation of these strategies to the school setting can be found in Health Promoting Schools in Action in Aotearoa/New Zealand (Public Health Promotion, Auckland District Health Board, and Mental Health Foundation, 2001, pages 14–15).

In ratifying the Ottawa Charter, The Jakarta Declaration on Leading Health Promotion into the 21st Century (1997) states:

''

Health promotion, through investment and action, has a marked impact on the determinants of health [and can be used] to create the greatest gain for people, to contribute significantly to the reduction of inequities in health, to further human rights, and to build social capital.

''

Framework for health promotion analysis

The lists in the following tables provide a framework that teachers and students can draw on to analyse approaches to health promotion that are used in society or that they may choose to use themselves. For example, if they see a stop-smoking campaign that offers telephone counselling to help someone quit smoking, they can use the following lists to determine that the campaign was probably based on the self-empowerment model because its characteristics fit that strategy. The strategy helps people to know where, when, why, and how to seek help, and encourages independence.

Characteristics of the health promotion and health education models

Behavioural change model

  • Focuses on health professionals' perceptions of health needs – suggests that 'experts' know best.
  • Transmits knowledge – increases people's knowledge of the factors that improve and enhance health.
  • Educates 'about' health.
  • Uses health campaigns.
  • Uses the transmission approach to teaching – the learners are largely passive.
  • Often reflects 'healthism'*.
  • May have a 'moralistic' tone.
  • Emphasises disease and other medical problems so tends to be negative and deficit-focused.
  • Focuses on risks rather than on protective or preventive factors and takes a 'band-aid' approach.
  • Tends not to reflect the socio-ecological perspective.
  • Does not take into account determinants of health or consider who is responsible for health.
  • May imply 'victim blaming'.
''

[Healthism is] a set of assumptions, based on the belief that health is solely an individual responsibility, that embrace a conception of the body as a machine that must be maintained and kept in tune in a similar way to a car or motorbike.

''

Health and Physical Education in the New Zealand Curriculum, page 56

Self-empowerment model

  • Develops a sense of identity.
  • Promotes reflection in relation to others and society.
  • Encourages people to reflect and change their views.
  • Clarifies values.
  • Helps people to know where, when, why, and how to seek help.
  • Encourages independence.
  • Uses critical thinking and critical action in relation to oneself.
  • Uses the action competence process for the individual, recognising determinants that may be beyond their control.
  • Fosters resilience and empowerment at a personal level.
  • Enhances self-awareness.
  • Focuses largely on the individual.
  • Gives opportunities to celebrate individuality.

Collective action model

  • Encourages democratic processes and participation 'by all for all'.
  • Takes a student-centred/constructivist approach to teaching and learning.
  • Takes determinants of health into consideration.
  • Emphasises empowerment for all participants.
  • Educates 'for' health.
  • Uses a social action or action competence process to work with others.
  • Uses a whole community/school development approach.
  • Views teachers and students as social agents.
  • Uses critical thinking and critical action in relation to the individual, others, and society.
  • Takes a holistic approach – inclusive of hauora.
  • Is based on authentic needs.
  • Fosters resilience at wider community and societal levels – not just at an individual level.

contents based on Nutbeam (2000); and Colquhoun et al. (1997), derived from French and Adams (1986).

Example of using models in the context of smoking

How the behavioural change model would be likely to be used in the context of smoking:

  • using slogans, media messages, and pamphlets.

How the self-empowerment model would be likely to be used in the context of smoking:

  • providing access to medication, to telephone counselling, or to 'quit smoking' programmes and support groups to help people quit smoking.

How the collective action model would be likely to be used in the context of smoking:

  • working with vulnerable groups to analyse the issues according to the relevant determinants of health (for example, the impact of colonisation, cultural deprivation, poverty, and social exclusion);
  • engaging with a range of individuals and groups, including those affected, to identify needs, plan actions, and develop policies and support structures designed to address smoking across the population, providing support for identified groups.

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