From In Touch
Vol 20 No 1 January/February 2003
Australian Public Health Association

Susan Pettifer, Director of Health Promotion ,
Women



's & Children's Hospital, Adelaide
As a new member of the Health Promotion SIG, but a not-sonew
health promotion practitioner, I was in a quandary when
asked to write this column. In my work as Director of Health
Promotion at the Women's and Children's Hospital in
Adelaide practice challenges are never in short supply: I could
write about childhood obesity, alcohol and pregnancy or food
supply for aboriginal communities. However, the issue that
has occupied much of my thinking in recent months is the
term health promotion itself.
My belief is that we are witnessing a gradual erosion of the
concept of health promotion. Over the last two years in
particular, I have observed a subtle but discernible narrowing
of the meaning of the term, and in some cases its complete
disappearance. The words now seem to be primarily
employed to denote behavioural or lifestyle change programs
or programs using social marketing approaches.
I offer three brief examples. The first comes from the National
Mental Health Strategy's health promotion plans. The first
plan, entitled Mental health promotion and prevention action
plan (1999), was soon followed by the second, entitled
National action plan for promotion, prevention and early
intervention for mental health (2000). Since when did the
term health promotion not encompass prevention and early
intervention? This terminology of "(health) promotion,
prevention and early intervention" has replaced "health
promotion" in many mental health circles.
The second observation comes from the UK, where the Blair
government has initiated significant reforms to improve health
and to reduce health inequalities (Saving lives: Our Healthier
Nation, 1999). As part of these developments, Health
Promotion England was abolished and most of its functions
taken over by the new, larger Health Development Agency.
The Health Development Agency was created "to support
and enhance efforts to improve health and reduce
inequalities". Its priorities include coronary heart disease,
cancer, accidents, mental health, drug and alcohol use and
sexual health.
In discussions with British colleagues, I found that the term
health promotion seldom appeared. 'Health development' was
often used instead, due to limited understanding, and
frequent misunderstanding, of health promotion. I heard of
fierce debates over naming rights for new units and positions
in areas I would have referred to as health promotion practice.
Should they have directors of health promotion, directors of
public health or directors of population health promotion and
social health? The need to add the words 'population' or
'public' to health promotion suggested that health promotion
was no longer considered to include healthy public policy or
structural action.
The last example I offer is from the South Australian
Generational Health Review, a comprehensive report on the
state's health system initiated by the new Labor Government.
One of the limitations of the review papers to date has been
the way the term health promotion is applied. Once again, it
is generally used to describe health education or personal
behavioural and lifestyle approaches.
The timing of these developments is interesting. They have
come at the very time when policymakers, researchers and
practitioners are acknowledging the need to tackle structural,
environmental and behavioural aspects of health through
programs that target the individual, the community and the
settings in which they live and interact.
It has been known for decades, since the publication of the
Ottawa Charter for Health Promotion by the World Health
Organisation in 1986, that health promotion encompasses
more than health education and personal behaviour change.
The five action areas of the Ottawa Charter provide a
comprehensive framework for health promotion that moves
beyond the individual to take into consideration healthy
public policy, supportive environments, community action
and the reorientation of health services.
Can it be that the term health promotion just doesn't describe
these ideas and actions well enough?
I suspect that the source of these semantic dilemmas is partly
due to the connotation of the word 'promotion'. Whilst
development is often associated with acceptable words such as
'sustainable' and 'community', promotion is often seen along
side words like 'product' and 'campaign'. Despite years of
practice and a growing research base, the field of health
promotion is hampered by that word 'promotion'. I suspect
that, like me, my colleagues are frustrated by answering stray
enquiries about balloons for a launch, when the caller really
wanted the public relations department! To the general
public, 'health promotion' suggests alignment with public
relations or marketing. This is not a position of power when
advocating with government or clinicians.
So in the next decade, will those of us involved in community
programs that aim to improve health be talking about health
development, health promotion, health advancement or some
other overarching concept yet to be determined? Concepts
and the words we use to describe these concepts will and
should evolve over time, so I wait in interest.
Health promotion: Evolution or erosion?