Health Promotion and Education Health Article

HEALTH PROMOTION AND EDUCATION

The scope of health promotion is determined as much by expected health outcomes as by methods and forms. From its purpose to enable people to gain greater control over the determinants of their health, "health promotion" can be defined as "any combination of educational and environmental supports for actions and conditions of living conducive to health" (Green and Kreuter, 1999). The actions or behaviors in question may be those of individuals, groups, or communities; or of policymakers, employers, teachers, or others in organizations whose actions or practices control or influence the determinants of health. When the determinants are ones over which individuals can exert personal control, this control ideally resides with the individual. But with some aspects of complex lifestyle issues, especially those that affect the health of others (e.g., drunk driving, public smoking), the control that people exercise must be through collective decisions and actions. Such strategies are reflected in the social policy targets of health promotion, which may call for aggressive and even coercive measures to regulate the behavior of those individuals, corporations, and government officials whose actions influence the health of others.

Health education aims primarily at learning experiences and the voluntary actions people can take, individually or collectively, for their own health, the health of others, or the common good of the community. Defining health education as "any combination of learning experiences designed to facilitate voluntary actions conducive to health" (Green and Kreuter, 1999) emphasizes the importance of multiple determinants of behavior. It also suggests an appropriate matching of determinants with multiple learning experiences or educational interventions. Health education is a systematically planned activity, and can thus be distinguished from incidental learning experiences. Further, this construction of health education draws attention to voluntary behavioral actions taken by an individual, group, or community with the full understanding and acceptance of the purposes of the action—either to achieve an intended health effect or to build capacity for health.

Health education can be seen as enveloped by health promotion, with its aim of complementary social and political actions that can achieve the necessary organizational, economic, and other supports that enable the conversion of individual actions into health enhancements and quality-of-life gains. In essence, the task for health promotion, beyond health education, is how to make more healthful choices easier choices. The commitment to an educational approach to health promotion is part practical necessity, part political expediency, and part philosophical commitment to provide for informed consent and voluntary change before attempting to change social structures and ecologies.

That policy, organizational, economic, regulatory, and environmental interventions are necessary to accomplish the original intent of health education is not to disaffirm health education as the primary means for democratic social and behavioral change. Health education provides the consciousness-raising, concern-arousing, and action-stimulating impetus for the public involvement and commitment to social reform essential to its success in a democracy. Without health education, health promotion would be a manipulative social-engineering enterprise. Health education of the public keeps the social change component of health promotion accountable to the public it serves. Without the policy supports for social change, on the other hand, health education is often powerless to help people reach their health goals, even with effective individual efforts.

The evolution of health policy and programs for health promotion and education has reflected a shared responsibility among institutions, groups, and individuals that have an influence on health. From era to era, the balance of responsibility has swung like a pendulum between a heavy reliance on government and its institutions for environ-mental and policy change and a heavy reliance on individuals and families to change behaviors. Ideological attempts to shift the responsibility more exclusively from one side to the other have met with a seemingly inexorable cycle of political swings. The reality of program planning and execution is that both sides must be engaged.

Health promotion, encompassing health education, has achieved a shift in the locus of initiatives for health (and control over its determinants) from medical institutions and health professionals to individuals, families, schools, and worksites. This has occurred in a context of growing community, social, and technological support for shared responsibility for health. Worksite health promotion has expanded rapidly, with notable provisions for institutional supports for employee participation. Schools increasingly emphasize organizational and social factors in programs for the modification or development of diet and the prevention of substance abuse. In many communities, an emphasis is given to concerns about the environment and about housing and other conditions of living that shape lifestyles, health, and quality of life. All of this calls for greater collaboration among sectors, organizations, and individuals.

Achieving an optimum blend of responsibility appropriate to the local context and the health issue of concern requires more participatory and socially responsive strategies than have prevailed in past eras. Responsive strategies call for individuals, families, professionals, private organizations, governments, and local and national agencies to decide case by case how to divide and share responsibility for each health issue. Whatever the need or objective, participants must assess its urgency, causes, variability, distribution, and the extent to which people want and are able to influence its determinants. Those directly affected should have a voice in negotiating this division of responsibility. Providing opportunities for all voices to be heard derives from the principle of participation central to learning theory and effective community organization. It also affirms a linkage to the philosophical and ethical basis of the professional commitment to supporting voluntary rather than coercive change where possible.