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.
The Community and Health Promotion
The most appropriate "center of gravity" for health promotion is the community. Community health promotion requires the participation of local leadership and social networks to facilitate the transmission and uptake of interventions for the overall population, as well as environmental changes (e.g., legislating or enforcing policies) to support individual and organizational interventions to achieve social change. State and national governments can formulate policies, provide guidance, allocate funding, and generate data for health promotion purposes; and individuals can govern their behavior and control the determinants of their own health— up to a point—and they should be allowed to do so. Decisions on priorities and strategies for social change affecting the more complicated lifestyle issues are best made collectively, however, close to the homes and workplaces of those affected. This principle assures the relevance and appropriateness of the programs to the people affected, and it offers the best opportunity for people to be actively engaged in the planning process. It also reflects the evidence that has accumulated on the value of participation in learning and behavior— that people are more committed to initiating and upholding changes they helped to design or adapt to their own purposes and circumstances.
A "community" may be a town or county in sparsely populated areas; or it may be a neighborhood, worksite, or school in more populous metropolitan areas. It can also apply to groups of people not sharing a specific geographic association, but sharing social, cultural, political, or economic interests that link them together. Community represents, ideally, a level of collective decision making appropriate to the urgency and magnitude of a health-related issue, the cost and complexity of the solutions implied, the local culture and traditions of shared decision making, and the sensitivity and consequences of the actions required of people after the decision is made.
Ensuring the active participation of the people intended to benefit from a proposed program is an essential principle of health promotion. Community or citizen participation is a social process by which members of particular groups with shared needs in a community setting actively pursue identification of those needs and make decisions and establish mechanisms to meet the needs identified. Small group processes such as meetings, coalitions, and committee structures offer avenues for participation, set into motion by effective community organization or organizational development. An example is the Healthy Cities movement, where participation in small group processes was a powerful locus of change for individuals, organizations, and communities.
The principle of participation, critical at the local level, is of no less importance at the national and state levels. When policies and priorities set at one level depend on individuals or institutions at another, those responsible for planning health interventions need to make every effort to solicit active participation, input, and endorsement from that second level. Without such collaboration, the cooperation and support needed from the second level may not appear. Participation in this form requires acts of courtesy and respect, the time needed to foster dialogue, and, ultimately, trust.
Failure to engender cooperation is a major over-sight, as it can yield a threat to any proposed program. In contrast, consulting and reconciling differences through consensus decision making fosters trust and enables collaboration.
The Ecological Approach
Ecological approaches in health promotion view health as a product of the interdependence between the individual and subsystems of the ecosystem (e.g., family, community, culture, and the physical and social environment). To promote health, an ecosystem must offer economic and social conditions conducive to health and healthful lifestyles. These environments must also provide information and life skills that enable individuals to engage in healthful behaviors. Finally, healthful options among goods and services must be available. In an ecological context, all such elements are viewed as determinants of health. They also provide support in helping individuals modify their behaviors and reduce their exposure to risk factors.
The ecological view of behavior holds that the functioning of an organism is mediated by behavior-environment interactions. This concept of reciprocal determinism suggests that the environment controls or sets limits on behaviors that occur in it, and that changing environmental variables result in the modification of behaviors. The inference is that health promotion can achieve its best results by way of individuals, groups, and organizations exercising control over their environment. The reciprocal side of this equation, however, holds that the behavior of individuals, groups, and organizations also influences their environments. This leads to the credo that health promotion seeks to enable the empowerment of people by allowing them greater control over the determinants of their health, whether these are behavioral or environmental. In taking greater control themselves, rather than depending on health professionals to exercise the control for them, people should be better able to adjust their behavior to changing environmental conditions, or to adjust their environments to changing behaviors.
Reflecting its accent on the multiple interdependencies of the elements making up a social web, an ecological approach suggests the need for interventions directed at several levels within a community and at multiple sectors of a social system (e.g., health, education, welfare, commerce, and transportation). The specification and application of such a sweeping, holistic conceptual framework challenges the capabilities and time of practitioners. The specificity with which ecological guidelines can identify the particular levels and sectors in need of attention is inherently constrained by the infinite variety of interactions that can apply in each idiosyncratic organization, community, or other social system. As the effectiveness of any health promotion strategy depends on its appropriate fit with the people involved, the health issue of concern, and the environment in which it is to be applied, any practical application of the ecological approach must target specific levels and sectors of a complex system. A realistic strategy, therefore, is to intervene where one can, with reasonable certainty, match actions with needs and where one can be accountable for unexpected side effects. Careful, systematic planning and practice are essential.
Empowerment
Empowerment can exist at four levels: (1) the personal level, by gaining control and influence in daily life and in community participation; (2) the small-group level, through the shared experience, analysis, and influence of small groups on their own efforts; (3) the organizational level, through capacity building by influencing decision-making processes; and (4) the community level, by gaining and utilizing resources and strategies to enhance community control. Empowerment has been defined as "a process by which individuals gain mastery over their own lives and democratic participation in the life of their community" (Zimmerman and Rappaport, 1988). A more detailed definition highlights empowerment as "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 community life, and social justice" (Wallerstein, 1992). Participation is central to these definitions, not only as an outcome of empowerment but also as a means by which individuals can organize, assess resources, and plan strategies to achieve collective goals.
Empowerment is a multidimensional construct, implying individual change and change in the social setting itself. True environmental change is distinct from environmental support for behavioral interventions, with structural modification of the environment necessary to support empowerment as an outcome for community interventions. While some individually aimed actions may be sufficiently empowering for some individuals to engage in healthful behavior, others will enter or remain in the "at risk" population because collective action has not been achieved in addressing the broader, social forces that created the problem initially.
Understanding empowerment requires clarifying the counterpoint from which it evolves, widely conceived as a sense of powerlessness. For either individuals or groups, powerlessness accompanies marginalization. Central to powerlessness and marginalization are societal arrangements of power and property, related patterns of production and consumption, and the impact of social experiences as reflected by population patterns of health, disease, and well-being. Powerlessness concerns the expectancy that people, individually or collectively, cannot determine the outcomes that they seek. Health promotion aims to facilitate empowerment by enabling people to take greater control over the behavioral or environmental determinants of health.
It is sometimes helpful to distinguish individual empowerment from community empowerment, but movement away from a position of powerlessness nearly always occurs in the context of community. This interdependence is consistent with conceptions of individual and collective efficacy, whereby increases in self-belief and self-esteem enable people, individually and collectively, to take control of their environment. Low sociopolitical control, even among those who have high levels of control in other dimensions, may limit the effectiveness of health interventions. Individualistic approaches that do not provide meaningful opportunities to support new habits will yield few changes. The status quo of public policy often implies, however, that responsibility for health resides not with government or social structures, but with those individuals or groups suffering particular problems. Thus, health issues can be seen as problems of certain groups, rather than of the systemic determinants of conditions of living. The reality is that both individual and environmental factors must be addressed jointly to facilitate individual and community empowerment together with health and quality-of-life gains.
Public Health Strategies for Health Promotion and Education
Programs for health promotion and education apply integrated strategies appropriate to the local context. Most community programs to change health-related behavior are to some degree ecological, that is, they seek to influence the social norms, cultural values, and economic and environmental conditions that affect health behavior at the community level. Such programs usually focus on any combination of the following actions: (1) interventions to promote health and prevent the development of disease (primary prevention); (2) screening for early detection and treatment of previously unrecognized cases of disease (secondary prevention); and (3) activities to help persons with known or established disease to more successfully manage their disorder (tertiary prevention).
There are two alternative, but complementary, strategies by which actions directed at the social and behavioral determinants of health are undertaken in the local context. The "community intervention" approach seeks to effect change in the social determinants of health and disease in order to reduce the prevalence of unhealthful behaviors or increase the prevalence of positive health outcomes. The "high-risk," or "intervention-in-a-community," approach aims to identify people at greatest risk for disease, often in a specific community site, and to intervene selectively.
These two approaches compete for policy and fiscal support. They are sometimes combined, however, with the high-risk approach invoked in the service of a community intervention approach. A combination strategy might use interventions such as self-help materials, health education, workplace policy change, and health legislation. Settings for implementation could be practitioner-based as well as community-wide, extending further into the arena of state and national determinants of community health. Methods of intervention delivery could range from health professionals interacting with individuals and groups to centralized planning and the actions of community agencies, consultants, and legislators, as well as mass media initiatives. The scope of programs would vary with the time accorded to achieving change, and with the strength of institutional and political commitment.
Community programs ideally target health-related behaviors not simply as isolated acts under the conscious control of the individual, but as socially conditioned, culturally embedded, and economically impelled forms of living that reflect unconscious behaviors that often have health consequences or risks. Such a complex of related practices and behavioral patterns in a person or group, maintained with a consistency over time, constitutes a "lifestyle." Lifestyle is a composite expression of the social and cultural circumstances that condition and constrain behavior, as well as the consciously chosen personal behavior of individuals.
Pros and Cons of Community Interventions
Compelling reasons exist for undertaking community interventions for primary prevention. Only by changing risk factor distributions in the middle of the curve for an entire population—not by focusing on the upper reaches of the risk distribution—can communities expect to see their overall morbidity and mortality reduced significantly. Ecological actions for lifestyle change require the cooperation of various community sectors and people with sway over social policy and norms. Given such cooperation, a community intervention has an advantage over a high-risk intervention as it links education with structural modification of the environment. This increases the likelihood of successful behavioral change and reaches more people with a wider range of risk levels or propensities. As norms change and as supply industries (e.g., food stores and restaurants) adapt to a new pattern, the maintenance of changes no longer requires a high level of individual effort. A high-risk approach does not offer the potential for normative change, because it targets only a small percentage of the population at risk, and the causes of presenting cases (e.g., behavior) are not necessarily the causes of incidence in populations (e.g., social, political, and economic factors).
There is also an economic and political case for community interventions. This perspective maintains that mass prevention is an "investment" that produces a dividend of reduced morbidity and mortality; produces an informed electorate and a consumer demand through education; and that yields a broader spin-off of secondary benefits for community stakeholders in terms of costs averted, quality of life, and productivity. An informed electorate spurs political change, and consumer demand achieves commercial advantages. A reduced burden on medical care systems, and a reduction of costs associated with absenteeism and reduced productivity and achievement, benefits a wider range of stakeholders. Community interventions have greater potential than high-risk approaches to achieve these political and economic benefits. The mainstreaming, rather than marginalization, of health problems (e.g., substance abuse) gives them greater political support and the programs greater momentum.
The drawbacks of community interventions in primary prevention are the greater complexity and duration of programs and policies addressing lifestyle and health-related behaviors and conditions of living. It can be difficult to activate a community sufficiently to enable individual and collective change through the development and implementation of broad and meaningful intervention strategies. Inadequate implementation and low levels of penetration explain the limited success of many community interventions. Underlying these explanations are specific causes, including: (1) the appropriateness of the theoretical foundation on which a program is based; (2) the level to which theory is integrated with local logic and cultural concepts of health and disease; (3) the extent to which a community is truly active in planning and implementing interventions; and (4) whether interventions vary across several different levels of implementation (e.g., individual, small group, organizational, and community). Also important is the continuation of a program: Too few programs allow for a sufficient duration of exposure to achieve sustainable changes and outcomes.
Allowing for diffusion and utilization of interventions to shift risk factor distributions for entire communities requires more time than for projects targeting change only in high-risk groups. On the other hand, high-risk groups often require greater levels of exposure than the community in general, as more intensive and sustained outreach strategies are required to reach the last cohorts in the diffusion of knowledge and risk-reduction practices. In either case, the potential for realizing benefits depends on time for interventions to become established and achieve momentum, and program implementation should continue over the duration of a social intervention. Time is required to integrate program components, to achieve synergy among components, and to increase the potential for diffusion throughout the community. Time is also needed for feedback on the comprehensiveness of information diffusion channels in order to ensure that a knowledge-behavior gap is not created or exacerbated among subgroups in a community. This requires intensity of effort combined with appropriate adaptation at all phases of the program process—which, in turn, requires iterative appraisal of the processes of intervention delivery.
Given the cost and effort involved, community interventions have been criticized on the basis of perceived inefficiency or lesser effectiveness, relative to the high-risk approach and its greater efficacy by selective high-risk screening and intervention. Fueling this criticism is the reality that most communitywide efforts have yielded only modest gains attributable to the program, while the high-risk approach achieves more palpable benefits of prevention at the level of the individual. Weak motivation based on health rewards, however, is often replaced in community interventions with stronger motivators for individuals of the social rewards of enhanced self-esteem and social approval. Furthermore, for diseases with multiple determinants, the community intervention approach could be highly robust. If communities can realize a normative effect in reducing disease risk factors, the cost-effectiveness and efficiency (greater reach) of community interventions could surpass the greater efficacy of the high-risk approach for prevention. For instance, interventions targeting healthful behaviors and the reduction of environmental risks for chronic disease are likely to reduce morbidity and mortality from other diseases also influenced by the same lifestyle and environmental conditions.
In their capacity to shift norms, the evidence thus far suggests that some community interventions have, in their application, compromised what programs need in order to work in specific communities. A main pitfall of appropriate adaptation stems from the insistence of various advocates of community-based models that practitioners must distance themselves from anything that is not communitywide. Some of the theoretical and definitional literature on community strategies has implied or insisted that "community-based" must be synonymous with "communitywide." This leads to shunning the inclusion of prevention activities based in organizations or institutions. While it is expressed sometimes as a mere preference for mass media and centralized planning approaches to community programs, in its extreme forms it takes on an avoidance, if not hostility, to programs or activities that serve people at the one-to-one level, those that deal with high risk groups, and those that treat disease rather than restricting their focus to people who are well and who seek primary prevention measures.
Life is not so dichotomous for individuals who must anticipate a life course of progression in risk factors, in presymptomatic disease, and in diagnosed chronic disease. Nor are the individuals living at these various stages of progression living in isolation from each other. The organizations and institutions in which people at various stages on the spectrum of health and disease are living, working, and playing share mutual dependencies on each other. These considerations make a more comprehensive, spectrum-inclusive approach to health promotion and disease prevention, detection, control, and management more sensible and efficient.
The expectation that social norms will respond over the short term to intensive media and policy initiatives at the community level is overly ambitious. Most social norms are institution-bound as much as they are the product of broader mass media messages and images. Without the inward involvement of institutions and organizations in changing their own norms (rather than just outwardly cooperating in community-wide efforts), the occupants (employees, students, residents, customers) of those institutions will continue to follow norms dictated by their organizational surrounding.
In conclusion, health promotion and health education are complementary approaches to enable people to gain greater control over the determinants of their health. Whereas health education is concerned primarily with learning experiences and the voluntary actions people can take on their own, health promotion targets the social and environmental supports that can enable health education to meet its objectives. To assert that community is the most suitable locus for health promotion is not to overlook individual and societal factors as determinants of health, but that these should be appraised and targeted for change in terms of their meaning and importance in the community context. This will ensure the relevance and appropriateness of change strategies to the people affected. Further, it enables people to be engaged in the planning process themselves. Providing for participation at local and higher levels facilitates social, economic, and political change in the determinants of conditions in which individual and community health are nested, thus enabling individuals to modify their behaviors and reduce their exposure to risk factors. Identifying and targeting, where feasible and appropriate, those modifiable interdependencies between the individual and subsystems of the ecosystem that affect health is the essence of an ecological approach that enables individual and collective empowerment through greater control over the determinants of health.
(SEE ALSO: Behavior, Health-Related; Communication for Health; Community Health; Community Organization; Cultural Appropriateness; Mass Media; Planning for Public Health; Social Assessment in Health Promotion Planning; Social Determinants; Social Health)
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— MARK DANIEL; LAWRENCE W. GREEN
