The four levels of health promotion: An integrated approach

Pubfic Health

(1993), 107, 3t9-326

(~ The Society of Public Health, 1993

The Four Levels of Health Promotion: An Integrated Approach M. P. Kelly, PhD, 1 B. G. Charlton, MD 2 and P. Hanlon, MD 3

1Professor of Social Sciences, University of Greenwich; 2Lecturer, Department of Public Health and Epidemiology, University of Newcastle-Upon-Tyne; 3Director of Health Promotion, Greater Glasgow Health Board

Four levels of health promotion are identified: environmental, social, organisational and individual. It is argued that health promotion interventions should not be confined to one level but instead an integrated approach should be adopted, in which the relationships between the four levels and the outcomes at all levels ought to be considered and analysed. It is suggested that these four levels are used as a checklist when health promotion interventions are planned. Introduction This paper describes four levels of health promotion: environmental, social, organisational and individual, all of which have to be understood and integrated for successful health p r o m o t i o n interventions (See Figure 1). Many health promotion activities are only partially successful because they do not genuinely take account of the need for integration. This is a pity because great store has been placed on the potential of health promotion. It has been identified as important by organisations as diverse as the World H e a l t h Organisation ( W H O ) , 1 the British G o v e r n m e n t 2 and even University D e p a r t m e n t s of Public Health: 3 everyone, it seems, wants to get in on the act. H o w e v e r , without the integration proposed in this paper health p r o m o t i o n may become merely empty rhetoric, and everyone is likely to be disappointed. A closer examination of the many definitions of health p r o m o t i o n reveals not only a good deal of variation in the way the term is used, 4 but also much internal inconsistency and political and ideological hostility. 5 For example, for the W H O health p r o m o t i o n means the processes of enabling people to take control of and improve their health; 6,v for H M G o v e r n m e n t it seems to mean running a variety of services, especially health checks in primary care with a strong emphasis on individual responsibility; 2 for the medical establishment health p r o m o t i o n appears to be identified as a branch of preventive medicine; 8 while for the Society of H e a l t h Education and P r o m o t i o n Specialists ( S H E P S ) , health promotion means everything that they did previously as health educators plus o t h e r activities including community development and advocacy with a high political profile. 9 A n examination of the work of a large Health P r o m o t i o n D e p a r t m e n t shows a bewildering array of activities under the health p r o m o t i o n banner 1° and, with G e n e r a l Practitioners getting in on the act in the w a k e of the 1990 contract, health p r o m o t i o n seems set to b e c o m e the flavour of the decade. Correspondence to: Professor M. P. Kelly, School of Social Sciences, University of Greenwich, Woolwich Campus, London SE18 6PF.

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The four levels of health promotion

Commentators have attempted, with some success, to bring conceptual clarity to this profusion of activities, ideas and principles ::,12 but the linkages to research, to the scientific community, and to policy makers, planners and indeed the recipients of all this activity remain problematic. 13 Over the years health educators have developed and described a range of models and approaches which deal with many of the concerns of this paper (see Beattie, 1991 for a review:4). For example, the work of Tones and his colleagues :5 describes three categories of individual and social health education, and other authors have argued for integration. 4 We suggest that for theoretical and practical integration to be achieved, an account must be presented of the relationships between the individual, organisational, social and environmental worlds. Four Levels of Health Promotion

Environmental Physical environments may be pleasant and benign, or stressor-rich and dangerous, or any combination thereof. ~6,Iy Physical environments affect the total organism at the

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microbiological level: 18 they also affect the organism at the level of the macroenvironment including such things as homes, transport systems, working conditions and the milieu--internal and external. 19 Physical manipulation of the environment may be health promoting, health protecting or health damaging. The environment therefore cannot be ignored in a health promoting intervention. At the very least the environment provides the ecological background within which other types of intervention occur. 2° To accompany this environmental aspect of health promotion is an important multidisciplinary research and conceptual base to which autonomous scientific disciplines contribute, each in their own way. The environmental concern operates at several levels: cellular, organ or bodily system, and the whole person level, as well as at the group and species level. Therefore disciplines such as biology, physiology, anthropology, the environmental sciences and ecology have an important theoretical and empirical role. Concepts such as system maintenance, equilibrium, and homoeostasis are among the theoretical models which allow explanation and prediction in this area. One significant theoretical idea which health promotion may find useful in this regard is salutogenesis.21 In health promotion it is as important to understand survival as it is to pursue the reason for system collapse or pathogenesis. The environments which cells, organs and people inhabit are by definition hostile. It is as interesting to know about successful survivors as it is about failures within such hazardous systems. Salutogenesis focuses on the resources for survival in hostile environments of whatever kind. 22'23

Socml The second level of health promotion is at the level of social structure--patterns of group behaviour. Analysis of social structure can draw on such disciplines as sociology, political economy and jurisprudence. Interventions at this level might include a number of methods for altering group behaviour such as education, advertising and propaganda, community development projects, pressure group techniques such as demonstrations and media events, taxation and fiscal policy and--par excellence--changes in legislation and law enforcement. Social structures are difficult to conceptualise, and the relationship between group behaviour and individual behaviour is a frequent source of confusion. Social structures do not determine individual behaviour, neither are they simply the aggregate of numerous individual decisions. Rather the relationship between the individual and society is interdependent and reciprocal, z4 This is because social structures flow from the knowledge, ideas and rules which, on the one hand, the individual derives from their understanding of society, while on the other hand these choices themselves are constitutive of the nature of society. The result is that a multiplicity of apparently autonomous decisions will blend to produce homogeneity of outcomes of individual behaviour, 25 for example patterns of voting in elections, changing fashions in clothes, and social class gradients in morbidity. The dynamic and complex nature of social structures contributes to the fact that they are extremely difficult to manipulate: deliberate attempts to plan society are fraught with the problem of unintended consequences. 26,27 This has frequently been seen in relation to health, so that advertising campaigns aimed at reducing narcotic drug use actually seem to excite curiosity about it, educational programmes

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to provide information on the risks of smoking are strikingly ineffective, and laws to prevent dogs fouling the footpath are simply not obeyed or enforced. The uncertainties of social planning are, to some extent, inevitable, being the necessary adaptation of general principles to specific local circumstances. General statutes are made by governments, but their effectiveness depends on public assent, police administration and judicial interpretation (and all of these groups have a role in deciding which laws are made in the first place). Health promotion should proceed in an analogous fashion. The integrated model can allow us to escape from oversimplistic unidirectional causal models with doubtful consequences. It is the individual's experience of and within social structures which guides conduct. 2a,29 If scientific descriptions or government interventions fail to take account of this and to integrate across the levels identified in this paper, they may be ineffective, or even counterproductive in their effects on group behaviour.

Organisations The third level of potential intervention and analysis is that of organisation. Organisational theorists define organisations with reference to their structures, their operation and their decision-making mechanisms. 3° The study of organisations draws on the scientific and empirical expertise of administrative science, the policy maker, the planner and the manager. These supply a set of theories and models which describe the functioning of organisations, their formal and informal structures, internal cultures, relationships to the external environment, strengths and weaknesses and the way they change and develop. 3° At a conceptual level the idea of organisation is easy to grasp, in so far as institutions such as factories, hospitals or health centres have physical boundaries. But organisations are not simply the buildings which house them or the fences that surround them. An organisation is a set of relationships between people, patterned according to rules, procedures and precedent. These rules define the nature of the hierarchical and authoritative relationships between individuals. The organisation is also a set of relationships of an informal kind. Human beings talk to and interact with each other in ways which are not simply a product of the official institutional mission or relationships. Finally, relationships (formal and informal) exist with persons or agents external to the organisation--clients, consumers or users. These relationships and people's understandings of them constitute the social structures of organisations. Some organisations have, as an explicit function, the delivery of health promotion per se. A n example of an explicit function would be a Public Health Department or a Health Promotion Department. But there are other types of organisations such as schools, hospitals and health centres where the main function is not the delivery of health promotion or health education, but where there may be a commitment to the provision of such services as part of a broader set of organisational goals, e.g. within the broad overall curriculum of a school, or within the so-called hidden curriculum. All organisations, however, have a health promoting role via their own internal organisation, a factor recognised in the concept of healthy public policy. 31,32 Given that organisations represent a pattern of relationships and communication, including relationships of hierarchy and line management, the extent to which such organisations create and sustain human dignity, creativeness and growth, or the extent to which organisations alienate people from each other, crush individuality and generate

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stress as a consequence of their social structure must be considered. Organisations are the interface between the social level and the individual level. They are the settings in which people experience and define the world in which they live. People's knowledge and understanding of the social structure tends to be mediated through organisations.

Individual behaviour The last of the levels which need to be considered is that of individual human behaviour. Human behaviour and its understanding are not simply matters of common sense to be understood purely by intuition--there are scientific tools to hand. It is not useful to regard human response as absolutely individual, or as identical in everyone. Psychological models pursue a middle course. In particular psychological models are premised on the well-founded empirical observation that subject to socio-structural constraints, individual behaviour is partly predictable and that the energising force for human action comes from within the individual. A number of psychological theories have found widespread acceptance in certain types of health promotion. Health Locus of control theory 33, for example, contains several ideas about the way individuals either believe themselves to be 'in control', to be controlled by others, or see life principally as a matter of luck, chance or fate. If the intention from the health promotion viewpoint is to help people to stop smoking it makes a great deal of sense to approach both the health education and any accompanying skills differently, as to whether the targeted individuals are internally or externally oriented, or whether they view life fatalistically. The same persuasive strategy is unlikely to work for the three kinds of people. A different approach, the health belief model, a4,35 has been applied to a number of situations where preventive action is required, and within which assessment and attribution of risk is important. These and other models of human behaviour 36 lend individually targeted interventions a degree of precision following from the predictability which allows rational measures, and the possibility of evaluation. However, psychology alone, even with its sophisticated models of individual behaviour, cannot be the basis of health promotion. The psychological dynamics of individuals have to be integrated with the other levels identified in this paper.

Conclusion: An Integrated Approach The idea of levels of health promotion is neither original nor new 37 and indeed it may seem self-evidently true that environment, social structure, organisations and behaviour all mesh together in the way health care is provided--as indeed these elements mesh together in all spheres of life. However, it is rarely the case that when a health promotion initiative is introduced it explicitly tackles all four levels in an integrated way. What tends to happen is that a particular intervention is partial, being based principally at one level. For example, the initial government-sponsored HIV/AIDS TV campaigns (although not some subsequent work on HIV) operated entirely on individual behaviour, paying little or no attention to the broad environment in which people live, the social systems of which people are a part, or the services available to them. To preach responsibility and safer sex without a service back-up to teach the necessary skills, and without reference to the social systems which produce subcultures of drug abuse or sexual opportunities, is to be naive. Another example is health

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check campaigns which are frequently locked firmly into the organisationat level. T h e y usually provide a check, advice, leaflets and a cholesterol measure or other similar information. H o w e v e r , interventions only at an organisational level fail to address the environment in which health-damaging products such as cigarettes are located and easily available. T h e y also ignore the social structure which limits opportunities, creates 'needs' to smoke, and socializes young people into the acceptability and desirability of smoking. T h e y overlook the behavioural mechanisms and skills which would be required by young people to extricate themselves from social situations where risky behaviour might be encouraged. By contrast, we would advocate a style of health p r o m o t i o n which is on the one hand more focused with regard to objectively valuable interventions but which adopted a m o r e comprehensive and multilevel strategy for ensuring that these interventions were effective in terms of health outcome. Fewer initiatives and targets, perhaps, but targets upon which the full force of available scientific expertise could be brought to bear. O f course it would be quite wrong to suggest that health education and health promotion specialists and others are unaware of the limitations and partiality of what they do. A n d frequently they are not to blame. Health p r o m o t i o n receives a relatively small amount of the health budget, and policies are typically delivered from higher political levels, going through fads and fashions in ways that pay little or no attention to the subtleties of the arguments here. Funding and resources may seem inadequate for the multilevel approach we advocate but, without such an integrated, all-through model, successful intervention is compromised. A critical mass is necessary. If efforts and resources are spread too thinly they will simply be wasted. While we recognise the complexity of health promotion, we do not offer a negative agenda. Instead we make a plea that from the outset of any health p r o m o t i o n p r o j e c t - - b e f o r e planning begins, before evaluation is considered, before effort is devoted to devising appropriate indicators--the four levels of environment, social structure, organisation and individual are used as a check list to consider the likely consequences flowing from the desired intervention.

Acknowledgements Thanks to Harry Burns, Andrew Tannahill, Graham Watt, and to Roz Lipsy and Graham Taylor for illustration.

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