Health Education and Promotion

Question 1

What is Health Education?

Answer 1

Health education is the process of educating people about their health and helping them to voluntarily make health-enhancing behaviour changes.

This can include any planned activity designed to produce health or illness-related learning (Tones & Green, 2004)

Health education is described as a core component of Health Promotion

Question 2

What is Health promotion?

Answer 2

Ottawa Charter for Health - WHO (1986):

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

Question 3

Describe the habit loop.

Answer 3

Cue/trigger: can be a person, place, time, a thing or even an emotion

Routine: behaviour to reinforce/change

Reward:
makes doing the routine worthwhile
positive reinforcement
keep habits going – maintains behaviour

Duhigg (2012)

Question 4

What are the 3 phases of habit formation?

Answer 4

Initiation phase – define the new behaviour and context it will be practiced are selected

Learning phase – behaviour is repeated in chosen context to strengthen the context-behaviour association

Stability phase – the habit has formed and its strength has plateaued, habits persists over time with minimal effort

Question 5

How long does it take to form a habit?

Answer 5

66 days

Question 6

Explain the role of modelling and conditioning in habit formation.

Answer 6

Parents play an important role in encouraging and modelling good habits e.g., technology use, nutrition and sleep.

Birch (1980) - peer modelling was used to change children’s preference for vegetables. The target children were placed at lunch for 4 consecutive days next to other children who preferred a different vegetable to themselves (peas versus carrots). By the end of the study the children showed a shift in their vegetable preference which persisted at a follow‐up assessment several weeks later.

Classical conditioning – learning process based on a paired stimulus (e.g., Pavlov’s dogs)

Operant conditioning – behaviour response followed by a positive or negative reinforcer or punishment – reinforcement will encourage behaviour to increase or decrease.

Question 7

What is a health habit?

Answer 7

A health related behaviour that is firmly established and often performed automatically, without awareness.

Cue - behaviour - reward

Usually developed in childhood – i.e. tooth brushing

Stabilises around age 11 or 12yrs – likely to be maintained.

Initial develops due to specific positive outcomes i.e. parental approval, social acceptance.

Eventually becomes independent of the reinforcement process and is maintained by the associated environmental factors

It can be highly resistant to change

(Bargh, J. A., & Ferguson, M. L. (2000) Beyond behaviorism: On the automaticity of higher mental processes. Psychological Bulletin, 126, 925 – 945).

Question 8

Describe non-communicable diseases as causes of death in the UK

Answer 8

Non-communicable diseases (NCDs) caused 70% of deaths globally

6 out of 10 are Non communicable disease

Cause of death is useful in assessing the effectiveness of a country’s health care system and to focus public health actions. Road traffic injuries are the leading cause of death among 15 to 29year olds worldwide and Suicide is the second leading cause of death among 15–29-year-olds.

In total, tobacco use is responsible for the death of about 1 in 10 adults worldwide.

Non-communicable diseases – such as cardiovascular diseases, cancer and chronic obstructive pulmonary disease – account for 80% of deaths in the European Region.

More than 1 in 17 adults in the UK have diabetes; 90% have type 2 diabetes, which is associated with lifestyle. Being active can
reduce the risk of developing this condition by 30-40%. PHE 2014
One in eight women in the UK are at risk of developing breast cancer at some point in their lives. Being active every day can reduce that risk by up to 20% and also improve the lives of those living with c a n c e r.
Dementia affects 800,000 people in the UK.

Question 9

What are the benefits of physical activity according to the NHS?

Answer 9

up to a35% lower risk of coronary heart disease & stroke
up to a 50% lower risk of type 2 diabetes
up to a 50% lower risk of colon cancer
up to a 20% lower risk of breast cancer
30% lower risk of early death
up to an 83% lower risk of osteoarthritis
up to a 68% lower risk of hip fracture
a 30% lower risk of falls (among older adults)
up to a 30% lower risk of depression
up to a 30% lower risk of dementia

Question 10

Give facts about physical activity and death

Answer 10

Physical inactivity is the fourth largest cause of disease and disability in the UK (Public Health England 2014)

Inadequate physical activity Costs UK society £7.4 billion annually
(£1 billion to NHS alone) www.nice.org.uk

Question 11

What is the cost of treating obesity on the NHS?

Answer 11

The cost to NHS of treating obesity is estimated at up to £6 billion per year

£49 million for treating obesity
£1.1 billion for treating the consequences of obesity
Indirect costs of £1.1 billion for premature death
£1.45 billion for sickness absence.

The cost of obesity plus overweight is estimated at up to £7.4 to 8 billion per year

Question 12

How many people smoke in the UK? What are the effects of smoking and how much does it cost the NHS?

Answer 12

14.7% of people (7.2 million) in UK smoke

Smoking causes a wide range of illnesses, including various cancers
(lung cancer is the most significant),
respiratory diseases, and
heart disease.

Smoking costs the NHS between £87.7 million services to aid quitting
£58.1 million medication to aid quitting (2012-13)

BUT cigarette sales made the government £9.5 billion excluding VAT in 2014-15

5.4% to 6.2% of people in UK vape using electronic cigarettes (2017-18). Health impact not fully known as yet.

Question 13

Give facts about alcohol.

Answer 13

Alcohol misuse is associated with 150,000 hospital admissions each year.

Around 70% of A&E attendances between midnight and 5am on weekend nights are alcohol related.

The loss to the economy of premature death from alcohol misuse is around £2.4 billion each year

Around 25% of children aged 11–15 drink alcohol, and they drink an average of around 10 units per week.

360,000 incidents of domestic violence are linked to alcohol misuse, around a third of all domestic violence.

Half of all violent crimes are alcohol related.

Up to 17 million days absent from work are alcohol related (Mondays!)

Question 14

What are the ethical problems of health promotion?

Answer 14

Information may not benefit all groups – especially the vulnerable.

Coercion – appear in top-down approaches legislation or social marketing

Manipulation
Social marketing = aim to make people do something that they have not (actively) chosen themselves for reasons they are unsure of
Scare campaigns= aim to influence behaviour through emotional reaction – exaggerations/misinformation e.g, drink driving/smoking campaigns

Question 15

What are the 5 key principles of health promotion (WHO, 1984)?

Answer 15

Involves the population as a whole in the context of their everyday life, not only ‘at risk’ groups

Focus on the determinants of health (upstream approach) & requires close co-operation between sectors (national to social).

Combines diverse but complementary, methods and approaches includes legislation and fiscal measures, organisational change and community development, to education and communication.

Involves public participation, involving decision making and problem-defining both at individual and collective level.

Primarily a societal and political venture and not a medical service, although health professionals have an important role.

Question 16

What are the 5 key strategies the Ottawa Charter determined would be needed to enhance public health?

Answer 16

Building Healthy Public Policy –The aim must be to make the healthier choice the easier choice. E.g., policies on guidance around nutrition labelling, number of units of alcohol you should drink a week, ban on fast food outlets within 400m on schools

Creating Supportive Environments – Improves living conditions: safe, stimulating, satisfying and enjoyable. Supportive environment – exercise – outside equipment parks

Strengthening Community Action – draws on community resources to provide social support and self-help for the community. E.g., exercise groups/walking groups/

Developing Personal Skills – improving access to health information and services enabling people to make a more informed health decision. Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves.

Reorienting Health Services – The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health-care system that contributes to the pursuit of health.. i.e., providing better access to health services for the disadvantaged, strong attention to health research as well as professional education/training

Question 17

What are the 3 areas of action for WHO’s Health promotion strategies?

Answer 17

Health education – intellectual, psychological & social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family & community well-being. This process is based on scientific principles and facilitates learning and behavioural change in both personnel and consumers, including children.

Service improvement – Promoting change in services to make them more effective, accessible or acceptable to the community.

Advocacy – activities directed at changing policy of organisations or governments.

(Hubley & Copeman, 2013)

Question 18

What are the 5 models of health promotion (Naidoo and Wills 2000)?

Answer 18

• Social change approach
• Behaviour change approach
• Medical approach
• Educational approach
• Self empowerment approach

Question 19

Describe the medical (or preventative) approach (aim, process, assumption and limitations)

Answer 19

Targets: Risk groups or risk behaviours with medical interventions.
Main concept is that of risk. Aims to reduce mortality.
Limitations: Emphasis is on individual responsibility “victim-blaming”
Individuals should reduce exposure to risk by avoiding risky behaviour and contact with risks in the environment.
Ignores the wider social and environmental determinants of health
Behavioural and lifestyle factors brought under control of experts, rather than encouraging individual competency.
Removes health decisions from lay people & emphasises compliance
Promotes undue dependence on the medical profession

Assumes: Application of Medical knowledge (evidenced based practice)
Expertise belongs to technical, professional authority of professionals - paternalistic
Compliance by patients required. Non-compliance = deviance.

Summary: Attempts to improve health = use of health education interventions to persuade individuals to adopt health behaviours and avoid risk.

Question 20

Describe the behavioural approach (aim,objective, method process, assumption and limitations)

Answer 20

Aim: To change attitudes and behaviours, so individuals adopt a ‘healthy’ lifestyle

Objective: To bring about changes in individual behaviour through changes in individuals’ cognitions.

Method: Provision of information about health risks and hazards.
Conceptually under-pinned by psychological theory.

Assumes: Humans are rational decision-makers whose cognitions inform their actions. Health is a property of individuals. People can make real changes by choosing to.

Limitations: Operates top-down from experts to public – disempowering.
Assumes there is a direct link between knowledge, attitudes, intentions and behaviour when this may not be true.
Could imply victim-blaming approach.
Assumes homogeneity among receivers of health promotion messages – does not account for individual differences.

Question 21

Describe the educational approach (aim, objective, process, assumption and limitations)

Answer 21

Approach used widely, informally and opportunistically, in many settings and sectors.

Aim: To provide knowledge and information and develop necessary skills so that people are empowered to make an informed choice about their health behaviour.

Objectives: To enable personal choice

Method: Giving knowledge, information and skills development to make an informed choice. It does not set out to persuade or motivate change in a particular direction. e.g., Provision of leaflets, booklets.

Assumes: The relationship between knowledge and behaviour; that by increasing knowledge there will be a change in attitudes which may lead to changed behaviour.

Limitations: Increasing knowledge and changing beliefs or attitudes does not necessarily lead to changes in behaviour.

Question 22

Describe the self-empowerment approach (aim, objective, process, assumption and limitations)

Answer 22

Aim: To increase control over the individual’s physical, social and internal environments.

Objective: To empower individuals to make healthy choices. “Health promotion is the process of enabling people to increase control over, and to improve their health” WHO (1984).

Process: Participatory learning techniques - group work, problem-solving techniques, client centred counselling

Assumption: Power is a universal resource which can be mobilised by every individual

Limitations: Inadequate concept of power - people are not equal in their ability to put healthy choices into action.
Long-term, time consuming? Cost-effective?
Assumes rational choices are healthy choices
Artificial environments used for training (role play, support groups) vs real world.
Powerful people are often reluctant to yield to suggestions to empower the powerless.
Model is not targeted at population groups therefore unlikely to affect social norms.

Question 23

Describe the social change approach (aim,objective, method process, assumption and limitations).

Answer 23

Aim: To change the physical, social and economic environment making it more conductive to good health.

Objective: To improve health by addressing socio-economic and environmental causes of ill health. Change society.

Methods: Individuals organise and act collectively to change their physical and social environments. Lobbying, change within organisations.

Assumption: Communities of individuals share interests which allows them to act collectively.

Limitations: Most health care professionals have limited role in developing policy
May require major structural changes
Requires political support from the highest level, e.g. through legislation
Vulnerable to lack of funding and to official oppositions
Needs support of the public
Benefits do not depend on people’s awareness of their existence – can be over looked and taken for granted.

Question 24

Give examples of legislations that support health promotion.

Answer 24

Compulsory wearing of car seatbelts
Smoking ban in public places
Health and safety at work - SGUL
Food labelling
Air pollution
Road safety – drunk driving 
British safety standards on consumer goods
School curriculum – health teaching (diet, exercise, sex education & provision) provision of free milk, free lunches

Question 25

Who can behaviour change interventions be aimed at?

Answer 25

Interventions can be aimed at:

Patients
Disease management, e.g. diabetes self-management
Health behaviours, e.g. weight loss, stopping smoking

Healthcare professionals
Guideline implementation, e.g. drug prescribing behaviours
Patient interactions, e.g. referral to services

General population
Preventative health, e.g. alcohol use, condom use

Question 26

What is a theory?

Answer 26

What is a theory?
A coherent description of a process, developed through inference
Provides an explanation for phenomena
Generates predictions (West and Brown, 2013)

Question 27

Why do we need theory led design?

Answer 27

To change behaviour, need to understand current behaviours and context

Appropriate (systematic) targeting increases effectiveness: efficient use of resources
Alternative is “trial and error” or “common-sense”

Consider appropriate mediators
Evaluate proposed mechanisms of action

Conclusions facilitate accumulation and integration of evidence → refine theory
Context, population and behaviour
Effects and causal mechanisms

Question 28

Why should we use frameworks and guidelines?

Answer 28

Need a methodical process, i.e. to ensure efficient use of resources
Ethical approval – need to safeguard everyone involved especially patients)