THIS ISSUE:

A SENSIBLE DRINKING PROGRAMME

USING HEALTH PROMOTION MODELS

By: Kemi D. Dele-Ijagbulu (MBChB, PGDip, MPH)

kemiowonibi@gmail.com www.kemidele.com

april 2014

Abstract This article provides a brief introduction to the concept and definition of Health

Promotion describing it as an evolving discipline and also demonstrates how health

promotion models can be used in addressing contemporary issues such as the harmful

effects of Alcohol. Beattie model is used to introduce a sensible drinking behavior.

@kemidele.com

1. THE MAIN FEATURES OF HEALTH PROMOTION

1.1. INTRODUCTION

Today’s concept of health promotion was adopted at the First International Conference

on Health Promotion in Ottawa in 1986 which defined health promotion as the process

of enabling people to increase control over and to improve their health. Health is

redefined as a resource for everyday life rather the objective of living and as a positive

concept emphasizing social and personal resources, as well as physical capacities. The

Ottawa Charter recognized eight fundamental resources described as prerequisites for

health, which are peace, shelter, education, food, income, a stable ecosystem, sustainable

resources, social justice and equity. Hence, health promotion is not just the responsibility

of the health sector (WHO 1986: 1-4).

Health promotion is an umbrella term for a range of health-related activities. The concept

focuses around five main action areas: build healthy public policy, create supportive

environments, strengthen community actions, develop personal skills and re-orient

health services. Its spectrum draws on the individualistic health education approach,

health protection, disease prevention as well as the bigger picture that impacts people’s

health, such as socioeconomic policies at local and national levels, preventive health

services, community based work, organizational development, public policy and

economic regulatory activities (Ewles & Simnett 1999: 25, 40). It widens up the

traditional biochemical model of health to one that includes bio-psychological, socio-

ecological and political economic models of health; addresses the determinants of health

and has a strong equity focus (Birn et al 2009: 133-134).

1.2. DEFINITIONS OF HEALTH PROMOTION

Many definitions of health promotion build on the themes of the Ottawa charter,

differences being in broadening definition for health and in their emphasis. While the

earlier definitions focus on health education and disease prevention, more recent

descriptions reveals a shift in focus to issues like investment for health, the need for

political advocacy, regulatory interventions, investment in strategies and infrastructure

that addresses the determinants of health and building health promotion capacity and

partnership, and as described by the Jakarta Declaration and the Bangkok Charter

(Nutbeam 1998:351; Smith et al 2006: 340; WHO 2005).

Below are other common definitions of Health promotion.

"Health promotion is any combination of health education and related organizational,

economic and political interventions designed to facilitate behavioural and

environmental changes conducive to health." (Green 1979: 161)

Health Promotion is the provision of information and/or education to individuals,

families, and communities that-encourage family unity, community commitment, and

traditional spirituality that make positive contributions to their health status.

Health promotion represents a comprehensive social and political process, it not only

embraces actions directed at strengthening the skills and capabilities of individuals, but

also action directed towards changing social, environmental and economic conditions so

as to alleviate their impact on public and individual health.

American Journal of Health Promotion (1989) defined Health promotion as the science

and art of helping people change their lifestyle to move toward a state of optimal health.

Optimal health is defined as a balance of physical, emotional, social, spiritual and

intellectual health. Lifestyle change can be facilitated through a combination of efforts to

enhance awareness, change behaviour and create environments that support good health

practices. (O'Donnell 2009: iv)

"Health promotion is the process of helping people to take control over their lives so that

they can choose options that are health giving rather than those that are health risky."

(Vetter et al, 1999: 216)

"Health promotion includes strengthening the skills of individuals to encourage healthy

behaviours and it also includes building the healthy social and physical environments to

support these behaviours." (Health Canada, 2005)

And finally, the WHO Bangkok chatter defined health promotion as the process of

enabling people to increase control over their health and its determinants, and thereby

improve their health. It is the core function of public health and contributes to the work

of tackling communicable and non-communicable diseases and other threats to health.

(WHO 2005)

1.3. HEALTH PROMOTION STRATEGIES

Health Promotion embraces holistic view of health and participatory approaches; focuses

on the determinants of health – the social, behavioural, economic and environmental

conditions that are the root causes of health and illness; and uses multiple,

complementary strategies to promote health at the individual and community level.

The Ottawa Charter identifies three basic strategies for health promotion. These are

advocacy for health to gain support including political commitment to create the essential

conditions for health indicated above; enabling all people to achieve their full health

potential; and mediating between the different interests in society in the pursuit of

health. These strategies are supported by five priority action areas as outlined in the

Ottawa Charter for health promotion. (WHO 1986:1, Nutbeam, 1998: 350).

Figure 1: The main determinants of health. By Dahlgren and Whitehead 1993.

Determinants of health refer to the range of social, economic and environmental factors which

determine the health status of individuals or populations Health promotion strategies and

programmes should be adapted to the local needs and possibilities of individual countries

and regions to take into account differing social, cultural and economic systems. (WHO

1986:4)

The Ottawa Chatter recognises three major strategic approaches for health promotion:

Advocacy – a combination of individual and social actions designed to gain political

commitment or support for a particular health goal or program (Nutbeam, 1998:

350).

Enabling – working with others in a participative manner; and

Mediation – coming to agreement and negotiating a common goal

Health promotion strategies and programmes should be adapted to the local needs and

possibilities of individual countries and regions to take into account differing social,

cultural and economic systems. (WHO 1986:4)

The Jakarta Declaration on Leading Health Promotion into the 21st Century from July

1997 confirmed that these strategies and action areas are relevant for all countries; that

comprehensive approaches to health development are the most effective; that settings

for health offer practical opportunities for the implementation of comprehensive

strategies; that participation is essential to sustain efforts and that health literacy/health

learning fosters participation. (Nutbeam 1998:351)

The Bangkok Charter for Health Promotion in a Globalized World from August 2005 went

further to recognise some critical factors that newly influence health which include:

commercialization, increasing inequalities within and between countries, new patterns

of consumption and communication, global environmental change and urbanization; as

well as the new opportunities for cooperation which globalization has opened up to

improve health and reduce transnational health risks. (WHO 2005:1)

Other strategies and key competencies include:

Health Communication – the use of communication techniques and technologies to

positively influence the health of individuals, populations and organizations

Health Education – consciously constructed opportunities for learning improve

health literacy, including improving knowledge and developing life skills to enhance

health.

Self-Help/Mutual Aid – a process by which people who share common experiences,

situations or problems can offer each other support.

Organizational change – working within settings for health, to create supportive

environments that better enable people to make healthy choices.

Community Development and Mobilization – collective efforts by communities which

are directed towards increasing community control over the determinants of health

Policy Development – developing legislative and regulatory measures that protect the

health of communities and make it easier for individuals to make healthy choices.

1.4. WHAT HAS CHANGED?

Health Promotion is an evolving discipline; the concept of Health Promotion has further

developed since Ottawa in a sequence of international conferences and by many

stakeholder groups. Although the Ottawa Charter has been phenomenal in guiding its

development, the world has changed a lot since 1986 and there has since been a

broadening of the discipline to encompass wider agenda (Nutbeam 2008: 435). The

WHO’s first Health Promotion glossary was first published in 1986 with 69 definitions of

core concepts and principles used in the field (Smith 2006: 340). This was first revised in

12 years later with a re-definition of basic terms as well inclusion of new concepts and

issues such as disease burden, capacity building global health and social marketing

(Nutbeam 1998: 350; Smith 2006: 342). There has also been a recent emphasis on

chronic non-communicable diseases, with new challenges including economic, legal and

environmental policies, modifying risk factors, poverty and urbanization. Not that the

science and understanding of non-communicable diseases have advances so significantly,

it is because there has been a paradigm shift in the way in which public health problems

are conceptualized and addressed (WHO 2005; Nutbeam 2008: 435).

2. A SENSIBLE DRINKING PROGRAMME: BEATTIE MODEL APPLIED

2.1. INTRODUCTION AND MOTIVATION

The harmful use of alcohol is a worldwide problem resulting in millions of deaths. It

accounts for about 4% of the global burden of disease; alcohol ranks eighth among global

risk factors for death, while it is the third leading global risk factor for disease and

disability (WHO 2011: 31). It is not only a causal factor in many diseases, but also a

precursor to injury and violence (Rossow 2000: 398); and its negative impacts can spread

throughout a community and beyond. Alcohol consumption causes harm far beyond the

physical and psychological health of the drinker. It also causes harm to the well-being and

health of others. Social harm from drinking can be defined in terms of how they affect

important roles and responsibilities of everyday life: work, family, friendship and public

character. (WHO 2011: 34). Hence it becomes imperative to review a comprehensive

picture of harmful alcohol use and its health consequences and to employ effective

interventions aimed at reducing alcohol-related problems, considered within a health

promotion framework.

2.2. SCOPE

Drinking behaviour is shaped by individual choices and motivation, and also strongly

influenced by organizational, economic, environmental, and social factors (WHO, 2004:

22). Therefore, approaches that attempt to bring about change in drinking behaviour

through health education in combination with behavioural, environmental, policy and

organizational changes are likely to be the most effective.

The goal of this programme is to modify the drinking pattern by reducing the volume, the

frequency, modify the variability, encourage abstinence, discourage heavy drinking

including heave episodic ‘binge’ drinking. (WHO 2004: 22)

While no single theory dominates the health promotion practice given the range of health

problems and their determinants (Nutbeam and Harris 1999:15), the Beatties Model of

Health promotion is employed in the planning and implementation of this programme.

Figure 2: Using Beattie’s model to analyse Health Promotion. Based on Beattie 1991, 1993

The Beattie’s model consists of four quadrants, arranged on two axes. The two axes

represent ‘mode of intervention’ which can be authoritative (a top down approach) or

negotiated (a bottom up approach) and ‘focus of intervention’ which can be individual or

collective. The Beatties model suggest that in addressing a health issue, all the four

approaches should be used to form a coherent strategy. This is because not all

determinants of alcohol use can be tackled by using a single approach, but if the model is

applied, it is more likely that a greater range of social, environmental and economic

determinants will be addressed. (Warwick-Booth et al 2012:158).

2.3. AUDIENCE

This programme reaches out to people, groups and organizations that are critical to the

achievement of health in this community, including the government and politicians, civil

society, the private sector, non-governmental organizations and the public health

community.

2.4. HEALTH PERSUASION

Health persuasion is addresses the individuals and the practitioner plays the role of the

expert. The aim is to persuade and encourage people to adopt healthier lifestyles.

Individual Authoritative:

Advice

Education

Behaviour change

Mass-media campaign

Media advocacy and public communication efforts do have significant benefits in health

persuasion and can help shape the community. There is evidence that well devised and

adequately resourced programs incorporating mass media can improve health related

behaviours (Peter Howat et al 2004: 172). Advertising campaigns can encourage quitting,

so is counter advertising where necessary. The focus of these campaigns is most

frequently on drink–driving, youth drinking, alcohol and health, and social harm related

to alcohol use. The other category most commonly included focuses on domestic or family

violence, and alcohol use (WHO 2011: 52).

Communications channels are also important. While mass media channels are effective

in disseminating information about innovations to many people, peers are highly

influential in a person’s decision to adopt an innovation. (Downie R.A.S et al 1996:

134)Thus, using social networks to reinforce mass media messages is more effective than

mass media alone. In addition, when respected local leaders initiate or reiterate

information provided through mass media channels, the chances increase that

individuals and groups will decide to act which is consequently likely to be more

sustainable.

A combination of popular leaders’ recommendations, peer group approval, and mass

media messages, especially if enhanced by coordinated listening groups, call-in

opportunities, and face-to-face approaches, is a powerful impetus to adopt an innovation.

Other methods include use of leaflets/publications, policy and guidance, press centre,

multimedia centre, blogs, speeches, feature stories, newsletter, etcetera

2.5. PERSONAL COUNSELLING

Individual Negotiated:

Counselling

Education

Group work

Personal counselling is aimed at individuals, but issues are client-defined, client-led and

focus on personal development in order to empower them to have the skills and

confidence to take control over their health (Louise Warwick-Booth 2012: 155).

Practitioner is in the role of counsellor, working with people’s self-defined needs; for

example, a young man engaging in heavy drinking as a way of relieves the boredom of not

being able to get a job, the practitioner may facilitate him in developing skills and

opportunities for work, or volunteering opportunities that can contribute to work

experience.

School programs grounded in educational and behavioural change theory often result in

positive outcomes and have been generally with life skills training to target drinking

behaviours of young people. Likewise, tertiary institution programs are helpful. High-risk

students who were provided with a brief intervention based on principals of motivational

interviewing showed significant reductions in drinking rates and harmful consequences,

as well as a significantly greater deceleration of drinking rates and problems over time

(Peter Howat et al 2004: 171)

Other activities include increasing availability of self-help/advice resources at GP

practices, pharmacists, workplaces; developing a smartphone apps to be used alongside

sensible drinking programmes.

2.6. LEGISLATIVE ACTION

Collective Authoritative:

Legislation

Health surveillance

Policy-making and implementation

These are set of measures in a jurisdiction, social and other policies imposed on the

populations and aimed at protecting the population minimizing the health and social

harms from alcohol consumption. These measures may be in any governmental or

societal sector, and may include measures which are not directly aimed at alcohol

consumption (WHO 2012:40). The health practitioner plays in the role of custodian,

knowing what will improve the nation’s health

Pricing policies are regarded as among the most effective measures to reduce total

alcohol consumption and hence alcohol-related problems. Studies have indicated that a

rise in price will lead to a drop in consumption and a decrease in price will likely result

in additional alcohol related deaths (Peter Howat et al 2004: 168, WHO 2012:42)

Other legislative actions include

Raising the drinking age – this has be found to be associated with a reduction in

alcohol consumption and alcohol related problems among young people.

Placing restrictions on advertising and promotion of alcohol products – because

advertising and promotion act as reinforcing factors for alcohol consumption

particularly by young people

Alcohol Licensing and Alcohol Availability: There is substantial evidence that alcohol

availability is correlated with levels of consumption and ultimate harm; and

prevention regulations that are aimed at the sellers of alcohol are more effective than

prevention programs that rely only on education directed at individual drinkers. A

common means of controlling alcohol distribution is through government-sanctioned

licensing systems. (WHO, 2012: 43).

Server intervention and drinking environments: Server intervention programs

involve training servers employed to serve alcohol beverages in alcohol retail

establishments, including managers and door staff. Their main objective is to prevent

intoxication and drunk driving by their clients. Recommended serving practices

include providing food, slowing service to drinkers showing signs of intoxication,

refusing service to intoxicated or underage drinkers, and taking steps to prevent

intoxicated patrons from driving. (Peter Howat et al 2004: 166)

2.7. COMMUNITY DEVELOPMENT

Collective Negotiated:

Lobbying

Action research

Group work

Community development

Skills sharing/ training

Community development has been defined as actions that helps people to recognize and

develop themselves to respond to problems and needs that they share, to enfranchise or

emancipate groups and communities so they can recognize what they have in common

and how social factors influence their lives. (Louise Warwick-Booth 2012: 157). Here, the

practitioner is in role of advocate. Community development approaches are linked to

empowerment and communities that take action for themselves in addressing health and

the wider determinants of health.

For example, the residents may lobby the local council regarding whether or not to grant

licence to businesses to sell alcohol in their area. There may also be community initiative

to tackle anti-social behaviour in young people by encouraging other forms of activities

to relieve boredom, such as community clubs owned and governed by young people

themselves.

Other community development activities may include the following:

Promoting the formation of community support groups

Developing a mentorship system between ex-addict and current heavy drinker

Designing a competition at the workplace to encourage employees to quit collectively

2.8. SUMMARY

Effective health promotion leads to changes in the determinants of alcohol related

problems, both those within the control of individuals (such as decision-making) and

those outside their direct control in the social, economic and environmental arenas. The

most effective means of changing drinking behaviour is through a combination of

educational, organizational, economic and political actions.

3. BEATTIE’S MODEL IN CONTEMPORARY HEALTH PROMOTION

The Beatties model is a useful model for health promoters as it identifies a clear

framework for deciding a strategy and reminds them of the choice of intervention that is

influenced by social and political perspectives. Beattie’s model supports the notion, that

contemporary health promotion should not focus exclusively on any one single element,

such as disease prevention, or societal change (Tannahill 2008) by allowing us to analyse

the complexities of health promotion approaches and by demonstrating that many

agencies with many different approaches across all quadrants and axes are needed for

well-rounded health promotion policies and practice. Beattie’s model of health

promotion is a complex analytical model that acknowledges that health promotion is

‘embedded in wider social and cultural practices’ (Wills and Earle 2007, Chapter 5).

Beattie's model empowers both the person and community and concurs with the Ottawa

Charter.

The four quadrants represent the different ways in which health can be promoted by

professionals, governments, and individuals, through health persuasion techniques,

legislative action, personal counselling and community development. (Thomas and

Stewart 2005; Naidoo and Wills 2007, Chapter 5; Wills and Earle 2007, Chapter 5).

Governments and health care professionals typically work in a ‘top down’ authoritative

approach, through legislative action and health persuasion techniques. Here, advice and

recommendations are handed out, and policies and interventions designed to increase

uptake of these recommendations are established. The aim of this is to protect individuals

and communities. However, both of these approaches on their own may disempower

individuals through a ‘victim blaming’ culture and may therefore result in only limited

change (Thomas and Stewart 2005).

The personal counselling approach and the community development approach both seek

to negotiate health, empower and enhance knowledge, understanding, and skills. With

the personal counselling approach, this is achieved through a health professional

assisting the individual to develop and reach their goals, rather than acting as an expert

instructing them how to change. The community development approach is similar to this,

except that rather than focusing on individuals, the focus is on groups, such as local

community groups (Naidoo and Wills 2007, Chapter 5). Community development does

require an ‘enabler’ or facilitator who will help to drive the project, but the risk then is

whether this facilitator brings their own agenda to the project, thereby diverting

resources towards their own objectives rather than those of the community at large

(Thomas and Stewart 2005).

However the Beattie’s model does not give priority to issues like investment for health,

commercialization, global environmental change, and urbanization; including investing

in research evaluation, and its dissemination; collaboration, cooperation and integration

between sectors especially the corporate sector.

REFERENCES

Birn A.E, Pillay Y., & Holtz T.H., (2009). Ch. 4. The Political Economy of Health and

Development. Textbook of International Health. Global Health in a Dynamic World. New

York: Oxford University Press: 132-140

Downie R.A.S., Tannahil, C. & Tannahill D. (1996). Health Promotion Models and Values.

Oxford Medical Publications

Ewles and Simnett 1999.

Green L. (1979). National policy on the promotion of health. International Journal of

Health Education 1979 (22):161-168

Linda Ewles, Ina Simnett (1999). Promoting Health: A Practical Guide. Bailliere Tindall:

New York

Louise Warwick-Booth, Ruth Cross, Diane Lowcock (2012) Contemporary Health Studies:

An Introduction Polity press, UK

Nutbeam D., (1998). Health Promotion Glossary. Health Promotion International,

13(4):349-364

Nutbeam D., (2008). What would the Ottawa Charter look like if it was Written Today?

Critical Public Health, 18 (4): 435-441

O'Donnell M. P. (2009) Definition of Health Promotion 2.0: Embracing Passion, Enhancing

Motivation, Recognizing Dynamic Balance, and Creating Opportunities. American Journal

of Health Promotion: September/October 2009, Vol. 24, No. 1, pp. iv-iv.

Peter Howat, David Sleet, Bruce Maycock And Randy Elder (2004) Effectiveness of Health

Promotion in Preventing Alcohol Related Harm. Cutis University, Western Australia

Rossow, I. (2000). “Suicide, violence and child abuse: A review of the impact of alcohol

consumption on social problems”, Contemporary Drug Problems, vol. 27, no. 3, pp. 397–

433.

Smith B.J., Tang K.C., & Nutbeam D., (2006). WHO Health Promotion Glossary: New Terms.

Health Promotion International 21(4): 340-345

Vetter N, Matthews I. (1999) Epidemiology and public health medicine. Churchill

Livingstone.

WHO (2005). The Bangkok Charter for Health Promotion in a Globalized World. WHO,

Geneva

Wills, J. and Earle, S. (2007). Theoretical perspectives on promoting public health. In

Theory and research in promoting public health. Earle, S., Lloyd, C. E., Sidell, M. and Spurr,

S., Sage, London / The Open University, Milton Keynes.

Thomas, S. and Stewart, J. (2005). Optimising health promotion activities. Journal of

Community Nursing 19(1): 9-12.

Naidoo, J. and Wills, J. (2007). Models and approaches to health promotion. in Health

promotion: Foundations for practice. Naidoo, J. and Wills, J., Bailliere Tindall / Royal

College of Nursing.

Tannahill, A. (2008). Health promotion: The Tannahill model revisited. Public Health 122:

1387-1391.

Tones, K. (1987). Devising strategies for preventing drug misuse: the role of the Health

Action Model Health Education Research 2(4): 305-317.

World Health Organization (1986). Ottawa Charter for Health Promotion. WHO, Geneva

World Health Organization 2004. Global Status Report on Alcohol. WHO, Geneva.

World Health Organization 2011.Global status report on alcohol and health. WHO, Geneva