Topic X Health

Education and
Health
Promotion

LEARNING OUTCOMES
By the end of this topic, you should be able to:
1.

Explain the concept of health education and health promotion;

2.

Describe the aims, objectives and principles of health education;

3.

Discuss the theories and models of health education and health

promotion.

X INTRODUCTION
Health education is an essential tool of community health and it is vital because
the promotion, maintenance, and restoration of health requires that individuals,
families and the community at large understand health care requirements.
Health education is an integral part of health services and it is an important task
for all health personnel who are responsible for providing health care.

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Similar to general education, health education is a learning process where

changes in knowledge, feelings and behaviour of people are taken into account.
This approach deals with teaching the client and their families how to deal with
past, present and future health problems. The knowledge that they have gained
enables them to make informed decisions in order to better cope with temporary
or long term alterations in their health and lifestyle, and to assume greater
responsibility for their health. Now, let us look at the definition of health
education.

6.1

DEFINITION OF HEALTH EDUCATION

Health education can be defined as follows:

Health education is a process that informs, motivates and helps people to
adopt and maintain healthy practices and lifestyles, and advocate
environmental changes as needed.

Health education is also defined as follows:

Health education is a process which brings about changes in the knowledge
and attitude of people and thereby affects change in their health practices.

In the promotion, maintenance and restoration of health, this means that

community health clients (individuals, families and communities) must receive a
practical understanding of health-related information. An individual is any
person, regardless of age, gender or other characteristics. Families are groups of
individuals linked by ancestry, marriage or household and may be nuclear,
extended, biological, adoptive or other alternative structures.
A community may be a small group support system, club, school or
neighbourhood that share a common interest or cause. The clients have varying
needs and abilities, and they are in a variety of settings. Therefore, health
education is important in order to enable the clients to make knowledgeable
decisions, cope more effectively with alterations in their health and lifestyles, and
thus assume greater personal responsibility for their health.

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As lifespan increases, people are more likely to experience chronic illnesses

related to aging that require complex changes in diet, exercise, and lifestyle and
medical treatment (see Figure 6.1). Health education becomes crucial because of
such social changes.

Figure 6.1: Those with illnesses related to aging need to make changes

6.2

DEFINITION OF HEALTH PROMOTION

The field of health promotion has provided a new way of thinking about the root
causes of health and well-being. This thinking has sparked the development of
new approaches towards improving the health of individuals and communities.
However, before we can look at health promotion, we need to be clear on what
we mean by the term health, which is what we are trying to promote. So, let us
review the definition of health.
Health has been described as follows:
A state of complete physical mental and social well-being, and not merely the
absence of disease of infirmity, is a fundamental human right. The attainment
of the highest possible level of health is a most important worldwide social
goal whose realisation requires the action of many other social and economic
sections in addition to the health sector.
(WHO, 1978)

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This definition contains the concept of positive health. The concept of positive
health is used to describe not only physical fitness but the ability to meet mental
stresses, solve life problems and maintain emotional stability, as well as an
individuals ability to improve his or her own well-being. To achieve this, it
requires the adoption of a social model of health recognising a holistic and
positive approach and highlighting socio-cultural, economic, political and key
environmental determinants of health.
Health promotion has been defined as follows:
Health promotion is the process of enabling people to increase control over,
and to improve, their health.
(WHO, 1995:5)
Furthermore, in order to reach a state of complete physical, mental and social
well-being, an individual must be able to identify and realise aspirations, to
satisfy needs, and change along with the environment. Therefore, health is seen
as a resource for everyday life, not the objective of living. Health is a positive
concept that emphasises social and personal resources, as well as physical
capabilities. This means that health promotion is not just the responsibility of the
health sector but goes beyond a persons lifestyle to include his well-being.
Health promotion extends to the maintenance and enhancement of existing levels
of health through the implementation of effective policies, programmes and
services. Tones (2005) states that health promotion is any planned measure
which promotes health or prevents disease, disability and premature death.
Heath promotion is a process directed towards enabling people to take action.
Thus, promotion is not something that is done on or to people; it is done by, with
and for people, either as individuals or as groups (see Figure 6.2). The purpose of
this activity is to strengthen the skills and capabilities of individuals to take
action and the capacity of groups or communication to act collectively to exert
control over the determinants of health and achieve positive change. It suggests
that people and communities can bring about positive changes in their health
and well-being, and that improvement is achieved through personal endeavour
and the support of others.

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Figure 6.2: Among health promotions that can bring about positive change

This provides an alternative to a traditional medical model of health care

addressing the symptoms rather than the causes of ill health. It places medicine,
and indeed health, in a wider social context. This context acknowledges, accepts
and reveals the causes of ill health and health inequalities as not the sole
responsibility of individuals or health care services but that of a range of public
and private organisations including national and local government (Amos &
Munro, 2002).
It puts health on the agenda of decision makers in all sectors and at all levels,
directing them to be aware of the health consequences of their decisions and to
accept their responsibilities for health. This broadens the debate to include
identification of problems and possible solutions for promoting health.
Health promotion differentiates between those factors which are more within the
control of individuals, such as individual health-related behaviour and the use of
health services, and those factors which are outside the control of individuals,
which include social, economic and environmental factors, and the provision of
health services (Tones & Green, 2004). Health promotion addresses both areas. It
helps in providing individuals and groups with the knowledge, values and skills
that encourage effective action for health. It also helps to generate political
commitment for health-supportive policies and practices, the provision of
services and increased public interest, and demand for health.

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SELF-CHECK 6.1
1.

Define health education.

2.

Define health promotion.

3.

Explain the differences between health education and health

promotion.

6.3

AIMS OF HEALTH EDUCATION

Earlier, we discussed the concepts of health education and health promotion. Let
us now look at the purpose, the aims and the objectives of health education. The
purpose of health education is to help people to achieve health through their own
actions and efforts. The aims of health education are as follows:
(a)

To help people understand that health is the most valuable community

asset, and to help to achieve health through their own activities and efforts;

(b)

To develop a sense of responsibility for improvement of their health as

individual members of families and communities;

(c)

To develop scientific knowledge, attitudes and skills regarding health

matters to enable people to develop correct habits;

(d)

To educate people about the proper use of health services in whatever form
it is made available to them by the government; and

(e)

To alter behaviour which may have a direct or indirect influence on the

occurrence of spreading diseases in a given cultural setting. A culturally
relevant health education programme can be planned only after
understanding the behaviour in all its manifestations.

Therefore, health education begins with peoples interest in improving their

conditions of living and aims at developing a sense of responsibility for their
own health betterment as individuals, and as members of families, communities
or government.

ACTIVITY 6.1
What are other aims of health education? Discuss this in a group and
present your findings at your next tutorial.

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The objectives of health education are as follows:

(a)

To inform people or disseminate scientific knowledge on the prevention of

diseases and promotion of health;

(b)

To motivate people to change habits and lifestyles that are harmful to their
health to adopt a more conducive way of living that is healthy; and

(c)

To guide those who need the help to implement and maintain a healthy
way of living by showing proper community resources.

A health education programme should aim at bringing about changes in

knowledge, attitude, behaviour, habits and customs. Therefore, the focus of
health education is on people and on action. Health education is an integral part
of national health goals. Effective health education has the potential for saving
many more lives.

6.4

PRINCIPLES OF HEALTH EDUCATION

There are certain principles of learning that are used in health education. They
are as follows:
(a)

Credibility  This is the degree to which the message to be communicated is

perceived as trustworthy by the receiver. Therefore, good health education
is based on facts, so it must be consistent and compatible with scientific
knowledge and also with the local culture.
People will have trust and confidence if the health educator (e.g., the nurse
or doctor) is the communicator.

(b)

Interest  This is the principle that people will most probably not listen to
things that do not interest them. It should be kept in mind that health
teaching should relate to the interest of the people.

(c)

Participation  Participation plays an important role in health education. It

is based on the principle of active learning. Health education should aim at
encouraging people to work actively with health workers in identifying
their own health problems and in developing solutions and plans to work
them out. A high degree of participation tends to create a sense of
involvement, personal acceptance and decision making.

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(d)

Motivation  In every human being, there is a fundamental desire to learn.

In health education, motivation is an important factor. For example, if you
tell a woman who is overweight to reduce her weight because she might
develop a heart disease or her life span might be reduced, this may have
little effect. However, if you tell her that by reducing her weight she might
look more charming and beautiful, she might accept the advice. Motivation
is contagious, and one motivated person can spread motivation to the rest
of the group.

(e)

Comprehension  In health education, one must know the level of

understanding, education and literacy of people (to whom the teaching is
directed). For example, a barrier to communication is using words which
cannot be understood. Therefore, we need to consider the mental capacity
of the audience before teaching.

(f)

Reinforcement  Very few people can learn something new and retain it in
a very short time. That is why repetition is very important. Messages need
to be repeated in different ways in order to make people remember it.

(g)

Learning by doing  Learning is an action-process; not only memorisation.

It is important to integrate learning by doing.

(h)

Known to unknown  Start health education with what people understand

and then proceed to new knowledge. Use existing knowledge and never
expect health education to have quick results.

(i)

Setting an example  The health educator must set a good example in what
he/she is teaching. For example, in explaining the hazards of smoking, the
health educator will not be very successful in his teaching if he himself
smokes.

(j)

Good human relations  Sharing of information, ideas and feelings is easier

between people who have good relationships. Building a good relationship
with others goes hand-in-hand with developing communication skills.

(k)

Feedback  Feedback is one of the key concepts of the system approach. For
effective communication, feedback is very important.

(l)

Leaders  People learn best from people they respect and regard highly.

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SELF-CHECK 6.2
1.

State the objectives of health education.

2.

Discuss the principles of health education.

6.5

HEALTH PROMOTION PRACTICE

Health promotion practice is fundamentally concerned with addressing the

determinants of health. This includes the lifestyle factors related to peoples
actions, such as health-related behaviours (e.g., smoking, diet and physical
activity) and broader factors such as income, education, employment and
working conditions, and social and physical environments. These factors
combined create the conditions which determine health status at the individual
and community level.
Lifestyle is taken to mean a general way of living based on the interplay
between living conditions in the wide sense and individual patterns of behaviour
as determined by socio-cultural factors and personal characteristics (Hood &
Leddy, 2003: 211). The range of behaviour patterns may be limited by
environmental factors and also by the degree of individual self-reliance. The way
an individual lives may produce behaviours that are beneficial or detrimental to
health.
Health promotion is often seen as activities which focus on particular issues.
However, it is much more than that. Health promotion also covers the principles
that underlie a series of strategies that seek to foster conditions that allow
individuals and the population to be healthy and to make healthy choices
(Naidoo & Wills, 2005), for example, developing personal skills, strengthening
community action, and creating supportive environments for health, backed by
public health policy.
However, good health is not equally shared (Woodward & Kawachi, 2000) and
health inequalities exist within and across communities and are influenced by
social, cultural and economic factors. Health promotion aims at reducing
differences in current health status and ensuring equal opportunities and
resources to enable everyone to achieve their fullest health potential (Lucas &
Lloyd, 2005). 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, 2006). This
includes a secure foundation in a supportive environment, access to information,
life skills and opportunities for making healthy choices.

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ACTIVITY 6.2
1.

Does the government have the right to tell people how to manage
their own health?

2.

Discuss the possible reasons why some people might not be

prepared or not be able to engage in initiatives and activities to
improve their health.

What makes good health promotion? There are several aspects that make good
health promotion. Below are the aspects that need to be considered.
(a)

Building Healthy Public Policy

Health promotion activities should encourage and support all agencies and
workers to consider the consequences of their decisions on health. Health
promotion policy requires the identification of obstacles to the adoption of
healthy public policy in non-health sectors, and ways of removing those
obstacles. Joint action contributes to ensuring safer and healthier goods and
services, healthier public services and cleaner environments.

(b)

Creating Supportive Environments

Health promotion activities recognise that health cannot be separated from
other areas of life. Therefore, the priority is to create ways of living,
environmental conditions, working conditions and social structures which
are safe, stimulating, enjoyable, satisfying and conducive to good health.

(c)

Strengthening Community Action

Health promotion activities should be developed side-by-side with the
community to identify priorities for action and to develop strategies that
will work. This involves supporting, encouraging, informing and skilling
the community to take control of issues that are importance to them and to
determine how these issues will be dealt with.

(d)

Developing Personal Skills

Health promotion activities aim to support an individuals personal and
social development in their private and work lives. This is to ensure that
they have the skills and information to make choices which will promote
their health. This includes activities which will increase their capacity to
carry out actions in other areas such as in school, home, work and
community settings. Action is required through educational, professional,
commercial and voluntary bodies, and within the institutions themselves.

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(e)

Reorienting Health Services

Health promotion activities support the health system and all stakeholders
in the system to move beyond clinical and curative services to services
which aim at increasing and improving the health of the community.
Health services also need to embrace an expanded mandate that is sensitive
and respects cultural needs.

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Health promotion strategies can develop and change lifestyles and the
social, economic and environmental conditions which determine health.
Health promotion is a practical approach to achieving greater equity in
health.
To take health promotion into the twenty-first century and meet new
challenges, there are several priorities that need to be acknowledged.
(f)

Promoting Social Responsibility for Health

(i)

Avoid harming the health of other individuals;

(ii)

Protect the environment and ensure sustainable use of resources; and

(iii) Restrict production and trade in inherently harmful goods and

substances.
(g)

Increasing Investments for Health Development

Investment for health should reflect the need to address health and social
inequities, focusing on groups such as women, children, older people,
indigenous people, those in poverty and marginalised populations.

(h)

Consolidating and Expanding Partnerships for Health

Health promotion requires health and social development partnerships
among the different sectors at all levels of governance and society. This also
involves strengthening existing partnership and exploring potential new
partnerships.

(i)

Increasing Community Capacity and Empowering the Individual

There are several key strategies at a community level, which are listed as
follows:
(i)

Strengthening advocacy through community action, particularly

through groups organised by women;

(ii)

Enabling communities and individuals to take control over their

health and environment through education and empowerment;

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(iii) Building alliances for health and supportive environments to

strengthen the cooperation between health and environmental
campaigns and strategies;
(iv) Mediating between conflicting interests in society to ensure equitable
access to supportive environments for health;
(v)

Improving the capacity of communities for health promotion, which

requires practical education, leadership training and access to
resources; and

(vi) Empowering individuals, which demands more consistent, reliable

access to the decision-making process and the skills and knowledge
essential to effect change.
(j)

Securing an Infrastructure for Health Promotion

In order to secure an infrastructure for health promotion, new mechanisms
for funding it locally, nationally and globally must be found. Incentives
should be developed to influence the actions of governments, nongovernmental organisations, educational institutions and the private sector
in making sure that resource mobilisation for health promotion is
maximised.
Setting for health represents the organisational base of the infrastructure
required for health promotion. New health challenges mean that new and
diverse networks need to be created to achieve inter-sectoral collaboration.
Such networks should provide mutual assistance within and among
countries and facilitate exchange of information on which strategies have
proved effective.
Training in and practice of local leadership skills should be encouraged in
order to support health promotion activities. Documentation of experience
in health promotion through research and project reporting should be
enhanced to improve planning, implementation and evaluation. All
countries should develop the appropriate political, legal, educational, social
and economic environments required to support health promotion. In order
to achieve this, governments and individuals must work together in
collaboration to meet the world-wide health agenda.

ACTIVITY 6.3
What health promotion activities have you been involved in to date? In
a group, reflect on the activities done and their effectiveness.

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THEORIES OF HEALTH EDUCATION AND

HEALTH PROMOTION

A theory is a set of interrelated concepts, definitions and propositions that

present a systematic view of events or situations by specifying relations among
variables in order to explain or predict events or situations. Theory reflects ways
of knowing and understanding that may be tested in various ways.
There are a number of psychological theories that attempt to explain the different
variables that exert influences on an individuals behaviour. Psychological
theories of health-related behaviour have contributed a great deal and offered
ways of helping people to change their behaviour. Understanding the process
that takes place in relation to health-related behaviour is an important tool in
planning health promotion activities (Tones & Green, 2004). There are a number
of psychological theories that attempt to explain the different variables that exert
influences on an individuals behaviour.
(a)

Belief  The information a person has about a particular object. It usually

links the objects to some particular attribute. Information can influence
beliefs, which in turn can influence behaviour.

(b)

Values  Values are an important part of every culture. They are acquired
through socialisation and are the emotionally-charged beliefs about those
things that a person regards as important. Values are often broad and
influence the way we think about things in life. For example, values relating
to gender give rise to a number of attitudes towards motherhood or
employment for women.

(c)

Attitudes  These are more specific than values and describe relatively
stable feelings towards particular issues or objects. The link between a
persons attitudes and their behaviour is an unclear one. Sometimes
changing attitudes may cause a behaviour change, and sometimes
behaviour change may lead to attitude change (e.g., stopping smoking).

Theories and models provide a blueprint for planning, implementing and

evaluating health education programmes and activities. Theories and models of
health behaviour help us understand the nature of targeted behaviours and
guide health education and health promotion strategies.
Theories and models:
(a)

Help us understand better the nature of the problem being addressed;

(b)

Describe the needs and motivations of the target population;

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(c)

Explain how to change health status, health-related behaviours and their

determinants; and

(d)

Inform the methods and measures used to monitor the problem and the
programme.

Health education and health promotion programmes that are most likely to
succeed are those based on a clear understanding of the targeted health
behaviour. A number of health education models have been developed, as
described below:
(a)

Medical model  Most health education in the past has relied on knowledge
transfer to achieve changes. The medical model is primarily interested in
the recognition and treatment of disease and technological advances to
facilitate the process. The assumption of this theory is that people would act
to improve their health based on the information supplied by health
professionals.

(b)

Motivation Model  Health education started emphasising motivation as

the main force to translate health information into the desired health action.
However, the adoption of a new behaviour or idea is not a simple act; it is
process consisting of several stages through which an individual is likely to
pass before adoption. There are three stages in the process of change in
behaviour as follows:
(i)

Awareness: Interest;

(ii)

Motivation: Evaluation and decision-making; and

(iii) Action: Adoption or acceptance.

(c)

Social Intervention Model  An effective health education model is based

on precise knowledge of human ecology and understanding of the
interaction between the cultural, biological, physical and socialenvironmental factors.

SELF-CHECK 6.3
1.

What are the components most theories have in common?

2.

What are the different models of health education?

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HEALTH PROMOTION THEORIES AND

MODELS

There are a number of significant theories and models that underpin the practice
of health promotion. A theory is an integrated set of propositions that serves as
an explanation for a phenomenon. The use of theory can help in the planning and
delivery of health promotion programmes in several ways.
The main theories and models utilised are elaborated as follows:
(a)

These theories attempt to explain health behaviour and health behaviour

change by focusing on the individual. Examples include:
(i)

Health Belief Model;

(ii)

Theory of Reasoned Action;

(iii) Stages of Change Model; and

(iv) Social Learning Theory.
(b)

Theories that explain change in communities and community action for

health. Examples include:
(i)

(ii)
(c)

Community mobilisation
x

Social planning;

Social action; and

Community development.

Diffusion of innovation

Models that explain changes in organisations and the creativity of health

supportive organisational practices. Examples include theory organisational
change.

The main theories and models utilised can be summarised as follows:

(a)

Health Belief Model

This model was originally designed to explain health behaviour by better
understanding beliefs about health. It is still one of the most widely
recognised and used models in health behaviour applications. The rationale
is that even though an individual recognises the consequences of certain

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health behaviours, his/her decision to take action will be based on the

following factors. This model addresses the individuals perceptions of the
threat posed by a health problem (susceptibility and severity), the benefits
of avoiding the threat and factors influencing the decision to act (barriers,
cues to action and self-efficacy).
(i)

Susceptibility
The individuals beliefs about whether they are likely to contract the
illness.

(ii)

Severity
This represents the degree to which an individual perceives the
consequences of having the illness to be severe. Together, the two
elements of susceptibility and severity comprise what is known as the
perceived threat of illness, sometimes known as vulnerability.
The next two factors are concerned with the pros and cons of taking
some action to combat the illness.

(iii) Benefits
The degree of physical, psychological or financial benefit associated
with any form of action (benefits need to be achievable and
assessable).
(iv) Barriers
Any decision to act will have a number of consequences. There may
be a degree of physical, psychological or financial distress associated
with any form of action.
The next two factors may stimulate action.
(v)

Cues to Action
Cues are stimuli which can trigger appropriate health behaviour.
They can either be internal (perception of bodily symptoms or states)
or external (stimuli from the environment, e.g., health professionals,
media campaigns, etc.)

(vi) Diverse Factors

These include factors like environment, culture, class and personality
factors that may influence health behaviour.

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(b)

Theory of Reasoned Action and Theory of Planned Behaviour

Theory of Reasoned Action and Theory of Planned Behaviour (Fishbein &
Ajzen, 1975; Ajzen & Fishbein, 1980; Ajzen & Madden, 1986) explore the
relationship between behaviour and belief, attitudes, and intentions. Both
theories assume behavioural intention is the most important determinant of
behaviour.

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According to these models, behavioural intention is influenced by a

persons attitude toward performing a behaviour, and by beliefs about
whether individuals who are important to the person approve or
disapprove of the behaviour (subjective norm). The Theory of Planned
Behaviour differs from the Theory of Reasoned Action in that it includes
one additional construct, perceived behavioural control. This construct has
to do with peoples beliefs that they can control a particular behaviour.
Ajzen and Madden (1986) added this construct to account for situations in
which peoples behaviour, or behavioural intention, is influenced by factors
beyond their control. He argued that people might try harder to perform a
behaviour if they feel they have a high degree of control over it.
(c)

Stages of Change or Transtheoretical Model

The Stages of Change, or Transtheoretical, Model was initially published in
1979 by Prochaska. In the 1980s, Prochaska and DiClemente worked further
on this model in outlining the stages of an individuals readiness to change,
or attempt to change, toward healthy behaviours (Prochaska & DiClemente,
1986).
The Stages of Change Model evolved from research in smoking cessation
and also the treatment of drug and alcohol addiction. More recently, it has
been applied to other health behaviours, such as dietary changes.
Behaviour change is viewed as a process, not an event, with individuals at
various levels of motivation or readiness to change. Since people are at
different points in this process, planned interventions should match their
stage this process.
There are six stages that have been identified in the model:
(i)

Pre-contemplation  (Not thinking about changing behaviour) The

person is unaware of the problem or has not thought seriously about
change;

(ii)

Contemplation  (Can stay at this stage for quite a while) The person
is seriously thinking about a change in the near future;

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(iii) Preparing to change  The person is planning to take action and is

making final adjustments before changing behaviours;
(iv) Making the change  The person implements some specific action
plan to overtly modify behaviour and surroundings;
(v)

Maintenance  The person continues with desirable actions (repeating

the periodic recommended steps while struggling to prevent lapses
and relapse; and

(vi) Termination  The person has no temptation and has the ability to
resist relapse.
Prochaska et al. (1992) argue that whilst few people go through each stage
in an orderly way, they will go through each stage, which is helpful as it
enables us to understand that relapse is a part of the process and not
necessarily a failure on behalf of the person or health promoter. In fact,
individuals can go both backwards and forwards through a series of cycles
of change  like a revolving door. For example, many people who give up
smoking may actually stop and then relapse a number of times before they
achieve the change permanently.
It appears that there are certain conditions required for change to take
place:
(i)

The change must be self-initiated;

(ii)

The behaviour must become salient (one must recognise that

behaviour is harmful);

(iii) The salience of the behaviour must appear over a period of time;
(iv) The behaviour is not part of the individuals coping strategy;
(v)

The individuals life should not be problematic or uncertain; and

(vi) The social support needed is available.

(d)

Social Learning Theory or Social Cognitive Theory

Social learning Theory (Bandura, 1977), later renamed Social Cognitive
Theory, proposes that behaviour change is affected by environmental
influences, personal factors and attributes of the behaviour itself.
Understanding of this interaction can offer important insight into how
behaviour can be modified through health-promotion interventions.

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A person must believe in his or her capability to perform the behaviour (i.e.,
the person must possess self-efficacy) and must perceive an incentive to do
so (i.e., the persons positive expectations from performing the behaviour
must outweigh the negative expectations). A person must value the
outcomes or consequences that he or she believes will occur as a result of
performing a specific behaviour or action. Outcomes may be classified as
having immediate benefits (e.g., feeling energised following physical
activity) or long-term benefits.
(e)

Community Organisation and Other Participatory Models

We will look at the community level of change models. Initiatives serving
communities and population, not just individuals, are at the heart of public
health approaches to preventing and controlling diseases.
Community-level models explore how social systems function and change
and how to mobilise community members and organisations. They offer
strategies that work in a variety of settings, such as health care institutions,
schools, worksites, community groups and government agencies.
Communities are often understood in geographical terms, but they can be
defined by other criteria too. For instance, there are communities for shared
interests (e.g., neighbourhood watch, accident prevention, and slimmers
world) or collective identity.
Community organising is not a single mode of practice; it can involve
different approaches to effecting change. Tropman et al. (1995) produced
the best known classification of these change models, describing
community organising according to three general types: locality
development, social planning and social action. These models sometimes
overlap and can be combined.
(i)

Locality development (or community development)  This is process

oriented. With the aim of developing group identity and cohesion, it
focuses on building consensus and capacity;

(ii)

Social planning  This is task oriented. It stresses on problem solving

and usually relies heavily on expert practitioners; and

(iii) Social action  This is both process and task oriented. Its goals are to
increase the communitys capacity to solve problems and to achieve
concrete changes that redress social injustices.

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89

In a social action approach to community organising, self-interest is seen as

the motivation for action; community members become involved when
they see that it will benefit them to take action, and targeted institutions are
willing to make changes when they believe it is in their self-interest to do so.
Community organising seeks to expand participants sense of self-interest
to an ever wider sphere, from the individual or family level to their block,
neighbourhood, city, region and so on. Participants grow through this
process, learning to take an active role in shaping the future of their
communities.
Community organising is a process through which community groups are
helped to identify common problems, mobilise resources and develop and
implement strategies to reach collective goals. Comprehensive health
promotion programmes often use advocacy techniques to help support
individual behaviour change with organisational and regulatory change.
In recent years, innovative tools and methods for evaluation and
measurement have been developed to capture the successes of communitylevel health promotion efforts. Tobacco control/smoking prevention is one
area where programmes have been extensively evaluated.
Local tobacco control initiatives typically pursue four concurrent goals:
(i)

Raising the priority of smoking as a health concern;

(ii)

Helping community members to change smoking behaviour;

(iii) Strengthening legal and economic deterrents to smoking; and

(iv) Reinforcing social norms that discourage smoking.
(f)

Diffusion of Innovations Theory

Diffusion of Innovations Theory provides an explanation for how new
ideas, products and social practices diffuse or spread within a society or
from one society to another. Diffusion of Innovations Theory addresses
how ideas, products, and social practices that are perceived as new
spread throughout a society or from one society to another. According to
the late Rogers (1995), diffusion of innovations is the process by which an
innovation is communicated through certain channels over time among the
members of a social system. Diffusion theory has been used to study the
adoption of a wide range of health behaviours and programmes, including
condom use, smoking cessation and use of new tests and technologies by
health practitioners.

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Rogers (1995) describes the process of adoption as following a classic bell

curve, with five categories of adopters:
(i)

Innovators (active information seekers of new ideas);

(ii)

Early adopters (very interested in the innovation but not the first to
sign up);

(iii) Early majority adopters (need external motivation to get involved);

(iv) Late majority adopters (are sceptics and will not adopt an innovation
until most people in the social system have done so); and
(v)

Laggards (last to become involved by a mentoring programme or

through constant exposure and have limited communication
networks).

Usually when an innovation is introduced, the majority of people will

either be early majority adopters or late majority adopters, fewer will be
early adopters or laggards, and very few will be innovators (the first people
to use the innovation). By identifying the characteristics of people in each
adopter category, practitioners can more effectively plan and implement
strategies that are customised to their needs.
Another aspect of time considers the rate of adoption, which is the speed at
which an innovation is adopted by members of a social system. At the
individual level, adopting a health behaviour innovation usually involves
lifestyle change. At the organisational level, it may entail starting
programmes, changing regulations or altering personnel roles. At a
community level, diffusion can include using the media, advancing,
policies or starting initiatives.
(i)

A number of factors determine how quickly, and to what extent, an

innovation will be adopted and diffused. These factors are listed
below:

(ii)

The relative advantage of an innovation shows its superiority over

whatever it replaces;

(iii) Compatibility an appropriate fit with the intended audience;

(iv) Complexity  has to do with how easy it is to implement the
innovation;

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HEALTH EDUCATION AND HEALTH PROMOTION

91

Trialability  pertains to whether it can be tried on an experimental

basis; and

(vi) Observability  reflects whether the innovation will produce tangible

results.
(g)

Organisational Change Theories-Stage Theory

Among the many theories of organisational behaviour, two have shown
special promise in the area of public health: Stage Theory and
Organisational Development. Stage Theory of Organisational Change helps
to explain how organisations plan and implement new goals, programmes,
technologies and ideas. Organisations are believed to pass through a series
of stages with each stage requiring a unique set of strategies if the
innovation is to progress. A strategy that may be effective at one stage may
be wrongly applied at the next. An innovations current stage of
development must be correctly assessed and the proper strategies selected
in order to be successful in the application of Stage Theory.
Stage Theory can be said to comprise four stages:
(i)

Awareness  problems are recognised and analysed and solutions are

suggested and evaluated;

(ii)

Adoption  policies are formulated, and resources for beginning

change(s) are allocated;

(iii) Implementation  the innovation is implemented, reactions take place

and changes in roles occur; and
(iv) Institutionalisation  the policy or programme becomes an integral
part of the organisation, and new goals and values are a part of its
structure.
These stages are in sequence. However, movement can be forward,
backward or abandoned at any point in the process. There are some
criticisms of Stage Theory. First, the stages need to be better defined.
Second, the stage model is not yet complete since beyond
institutionalisation, there should be renewal, when a well-established
programme evolves to meet changing demands. Lastly, the factors known
to contribute to the programmes development at each stage need to be
expanded.

92

(h)

Organisational Development Theory

Human relations and the quality of life at work are often the targets of
Organisational Development Theory. This theory has been divided into two
main sections:

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HEALTH EDUCATION AND HEALTH PROMOTION

(i)

Change Process Theories  deal with the underlying dynamics of

change; and

(ii)

Implementation Theories  used to make sure the change is

successful.

Again, four stages can be identified for producing change in the

organisation:
(i)

Diagnosis  a specially-trained person, usually an outside consultant,

helps the organisation identify its most striking problems which
interfere with its functions;

(ii)

Action Planning  strategies are developed for addressing these

diagnosed problems;

(iii) Intervention  the consultant usually does not offer specific solutions
but will aid in problem solving among the organisations members in
group interactions; and
(iv) Evaluation  the effort of the planned changes is assessed, and these
changes in the organisation are allowed to settle.
The Stage Theory and Organisational Development Theories have the
greatest potential for creating positive health changes in organisations
when used together. One example would be using consultation
(Organisational Development) as the intervention in both the adoption and
institutional stages (Stage Theory) in an organisational change.

SELF-CHECK 6.4
1.

Explain the Diffusion of Innovations Theory.

2.

Discuss the differences between organisational change theory and

organisational development theory.

TOPIC 6

HEALTH EDUCATION AND

A
HEALTH PROMOTION
P

93

Heallth education
n is a processs that inform
ms, motivates and helps people
p
to
adop
pt and maiintain health
hy practices and lifesty
yles, and aadvocate
envirronmental changes as need
ded.

Heallth promotion
n has been defined
d
as th
he process off enabling people to
increease control ov
ver, and to im
mprove, their health.

Heallth promotion
n is complex and works on
o a numberr of levels an
nd this is
refleccted in the heealth promotio
on theories an
nd models discussed.

Heallth promotion
n is directed toward
t
action
n on the deterrminants or causes
c
of
healtth (e.g., food security,
s
pareenting skills, self-care
s
skills, social supp
port) and
comb
bines diversee, but compllementary, methods
m
or approaches
a
in
ncluding
comm
munication, education leegislation, orrganisational change, com
mmunity
deveelopment and spontaneouss local activitiies against heaalth hazards.

All health
h
professsionals and th
hose working within the heealth and sociial arena
havee an important role in nurturing, enabling an
nd practicing
g health
prom
motion.

Health Belief Model

Staages of Chang
ge Model

Health education

Social Learning
g Theory

Health promotion

heory of Reaso
oned Action
Th

Ajzen, I.., & Fishbein

n, M. (1980). Understandin
U
ng attitudes and
a
predictin
ng social
beh
havior. Englew
wood Cliffs, NJ:
N Prentice Hall.
H
Ajzen I.,, & Madden, T. J. (1986). Prediction
P
of goal directed
d behavior: Attitudes,
A
inteention, and perceived
p
beh
havioral contrrol. Journal of Experimenttal Social
Psy
ychology, 22, 453474.

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