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International year of the family report (phase 1): an overview of academic attempts to define the family

5. The theoretical distinction between health education and health promotion and its relationship to the family

Within the original brief for this project the terms health education and health promotion were used in a way which suggested that they were near equivalents, (‘health education/promotion’). The work completed during the project suggests that this is to oversimplify a complex area. In a recent article to commemorate the 50th year of the Health Education Journal Tones (1993) reviewed the history of health education and health promotion in post war Britain. He argued that historically there have been important ideological differences between proponents of health education and health promotion, which have in turn led to them favouring different policies and strategies when attempting to improve the nation’s health. The term ideology is used by Tones solely to refer to:

that constellation of values and associated beliefs which provide people with meaning in their personal and professional lives and which would, inter alia, influence their preferred ways of working (Tones 1993 p 126).

For Tones health education has traditionally been conservative in nature and based squarely within the medical model of disease. Here policies and intervention strategies have traditionally been ‘top-down’ and authoritarian in their approach. Within this model specialists provide knowledge to non-expert audiences; with the needs of the community seen as best determined by the medical profession who subsequently instruct individuals and families in the correct way to promote their health. This view of health education leads Watson (1993) to comment:

The practice of traditional health education, concerned as it is with promoting ‘healthy’ behaviours (healthy eating, exercise, drinking sensibly, and managing stress), and seeking to eliminate unhealthy behaviours (eating to excess, smoking and drinking to excess), has been likened in recent sociological enquiry to society seeking to impose control over individuals and ‘order’ populations through specific forms of health behaviour aimed at controlling bodies (Watson 1993 p 251).

By contrast health promotion, which Tones argues came increasingly to the fore in the 1970s, can be seen to be the ‘militant wing’ of public health. For Tones the ideological essence of health promotion can be captured under five central points: first, there is an emphasis upon de-medicalisation; second, there is an explicit acknowledgement of the importance of socio-economic and environmental (rather than individual or medical) influences on health; third, there is a call for the consideration of health issues in all areas of public policy; forth, the need for inter-sectional collaboration between informal, voluntary ‘not-for-profit’, commercial and statutory sectors is acknowledged and finally, and above all else, the need to remedy inequalities is advocated. Within the health promotion ideology the emphasis is upon ‘bottom-up’ strategies which attempt to empower the community and involve them directly in the determination of their own health needs and the ways in which they are best addressed. Here then there is more emphasis upon ‘felt needs’ as opposed to the professionally ascribed needs in health education. Tones draws a parallel between the ideology of health promotion and wider community development approvingly quoting the Gulbenkian Foundation:

Community development ... is concerned with the worth and dignity of people and (the) promotion of equal opportunity ... (it) ... is most needed in communities where social skills and resources are at their weakest ... (it) ... involves working with those most affected by poverty, unemployment, disability, inadequate housing and education and with those who for reasons of class, income, race or sex are less likely than others to be, or to feel, involved and significant in local community life (Calouste Gulbenkian Foundation 1984, quoted in Tones 1993 p 131).

A recent editorial commentary in Health Education Research (1992) makes a similar point to that of Tones in calling for research contributors to take explicit account of the impact of the wider socio-economic and socio-political contexts when reporting both the design and implementation of health education and health promotion programmes.

The WHO defines health promotion as ‘a unifying concept for those who recognise the need for change in the ways and conditions of living, in order to promote health’ (WHO 1986) and identifies five principles which reflect health promotion.

• Involving the population as a whole in the contexts of their everyday lives, (rather than the populations at risk for certain diseases).
• Being directed towards action on the determinants of, or causes of health
• Being diverse in methods and approach
• Involving effective and concrete public participation
• Not being a medical specialism

(WHO 1986).

Clearly the model constructed by Tones (and others) is one of ideal-types and he is the first to acknowledge that in reality many strategies aimed at the improvement of the communities health cannot be divided neatly into ‘politically correct’ bottom-up community empowering projects and blatant top-down manipulative or controlling programmes. Moreover, as Fieldgrass (1992 p 8) has argued health education has always had, and will continue to have, a pivotal role within wider health promotion strategies. This point is illustrated nicely by Clark (1993) who, in a recent discussion of the ethical issues faced by nurses engaged in health education, extends the concept of health education to include nurses in developing their clients’ decision making and assertiveness skills:

The health educator is required to be aware of these (ethical) issues and of the need to respect and develop personal autonomy with his/her clients ... This can only be achieved if the health educator begins to educate clients not just in the do’s and don’ts to promote and maintain health but also in the development of health-related life skills such as personal awareness and decision-making and assertive skills that will be helpful in their self-development (Clark 1993 p 535) brackets added.

Moreover, in reality in addition to the ideology lying behind the type of intervention programmes which are initiated to promote a community’s health it is also necessary to recognise the effect of such considerations as cost and the issues surrounding the striking of a balance between the extensiveness of a particular programme’s coverage and the intensiveness of the work.

Although the difference between health education and health promotion is in practice often clouded, the distinction is important when we consider the role of families in the promotion and maintenance of their health. As has be suggested in previous sections ideologically the family is often portrayed as the archetypal private domain and as juxtaposed to the public domain of many other areas of modern life. Almost by definition within the ideology of health education the aim is to change individual behaviours. The locus of health problems are squarely within individuals’ behaviours and there exists a built in tendency to stress aspects of ‘individual responsibility’. Often this is to the exclusion of adequate consideration of the environmental and structural constrains faced by individuals and families and the ways in which health damaging and health promoting behaviours exist within the cultural contexts of people’s daily lives (see section on lay-health beliefs). The danger then within the health education ideology is that it is all too easy to de-politicise health issues and lapses into what has often been termed ‘victim blaming’ (MacIntyre 1993). This potential danger would appear to be increased if health education is tied to or targeted at the family because ideologically the family stands for and is a private domain social institution. As MacIntyre writes:

...many health promotion or public health policies focus on individuals and their behaviours (DH 1992: SOHHD 1992: Reid 1992) A large proportion seem to be based on the principle that if working class 'people' could only become more like middle class 'people', then their rates of illness and premature death would become more like those of middle class people. An alternative approach would be to try to make working class 'areas' more like middle 'class' areas by improving the social and physical environment (MacIntyre 1993 pp 229-30)