Health promotion



  1. The medical model
  2. The behaviour change model
  3. The educational model
  4. The empowerment model
  5. The social change model

 1 Medical model


One of the famous stories of early health promotion concerns the Broad Street pump in Soho, London. In 1854, Dr. John Snow plotted cases of cholera on a map of London and noticed that they clustered around a water pump on Broad Street.  At that time, water in London was provided by a number of private companies, and Snow discovered that the death rate from cholera was much higher for people using water from two of these companies (71 deaths per 10,000 people) than the others (only 5 deaths per 10,000 people). Snow’s observation of the pattern of cases around Soho allowed him to carry out a natural experiment. He disabled the Broad Street pump by removing the handle (hi-tech or what?) and the cholera epidemic subsided in the area. From this, Snow was able to show that cholera was carried in water (Donaldson and Donaldson, 2000.)

Genetic counselling. Future parents are able to get important information about the possibility of their future child being born with a genetic disorder. Factors such as the age of the parents and the results of biological tests may be taken into account. Tests can be made on the unborn foetus, but such techniques are hazardous to the foetus.

Immunisation of children would also be a way of preventing illnesses.

The analysis of questionnaires about health behaviour could also be useful in helping people to adopt a healthy lifestyle.


Primary - people have a limited knowledge of what is threatening to their health There is a lack of knowledge about behaviours learnt in the home.

There are, however, a number of barriers to primary prevention including:


      we have only limited knowledge about what behaviours are threatening to our health, for example, it is only in the last forty years that we have discovered the very harmful effects of tobacco smoking

      we have a lack of knowledge about how we develop health-threatening behaviours, for example, some behaviours to do with diet or exercise develop over many years from our childhood

      a number of health behaviours are learnt in the home, for example, the children of smokers are more likely to smoke than the children of non­smokers

      at the time that health threatening behaviours develop, people often have little immediate incentive to practice health enhancing behaviours, for example the effects of smoking are felt in middle to later life rather than when people start smoking

   people are often unrealistically optimistic about their health

3 main reasons why primary prevention has been ignored

  1. Traditional structure of medicine
  2. Difficulty of getting people to practice healthy behaviours
  3. Difficulty in applying methods of attitude and behavioural change to health

2  The behaviour change model: like the medical model, this approach is ‘top down’, in that health ‘experts’ decide which behaviours are good or bad for health, then try to get people to change their lifestyles accordingly. A problem with this kind of prescriptive approach is that it under­mines individuals’ autonomy and it assumes that the experts always know best.


3  The educational model: this is also aimed at changing people’s lifestyles but, unlike the behav­iour change model which is instructional (that is, deciding what is good for people, then telling them to do it), it provides individuals with knowledge, information and skills so that they can make their own informed decisions about how to behave. This model assumes that individ­uals are able to make free choices once they are in full possession of the facts, but this ignores emo­tional, environmental, social and economic con­straints. Also, in principle it must allow individu­als to make an informed choice to lead an unhealthy lifestyle if they wish to, but in practice health educators tend to have a particular lifestyle in mind when they are presenting people with information (for example, a health education teacher who tells a group of children about the dangers of smoking would feel that he or she has failed if some of the children make an ‘informed choice’ to carry on smoking).


4          The empowerment model: this is a third approach aimed at getting people to lead health­ier lives but, unlike the other two, it is a ‘bottom up’, non-directive, client-centred approach. The role of the empowering health educator is to help people realize that they themselves would like to change their situation, and to help them develop the skills and confidence to do so. It helps indi­viduals gain more control over their own lives in the hope that they will be naturally drawn towards a healthier existence.  Self-Efficacy - If people feel they can carry something out they will. Therefore, if simple actions are required then people will feel more able to follow the advice (e.g. chip pan fires and back to sleep.

5  The social change model: this radical approach recognizes the strong links between health and the social and economic environment, and attempts to improve the former by dealing with the latter.


Health education has been defined as “any planned activity which promotes health or illness related learning; that is, some relatively permanent change in an individuals competence or disposition”.

Another definition is “any combination of learning experiences designed to facilitate voluntary adoptions of behaviour conducive to health”.

A third definition is “any combination of health education and related organisational, economic and environmental supports for behaviour conducive to health”.

There are two main perspectives on health: social regulationist and radical structuralist (Caplan 1993).  The social regulation approach focuses on modifying individual cognitions and providing the behavioural skills necessary for health behaviour change.  In contrast, the radical structuralist approach states that ill health is a product of unequal power in society.  According to this view health promotion concerns changing the ways society is organised and how its resources are distributed. 

Which of the following do you do?

Avoid contact with doctors when feeling okay
Avoid getting chilled
Avoid over-the-counter (OTC) medicines
Avoid overworking
Avoid parts of the city with a lot of crime
Avoid parts of the city with a lot of pollution
Check the condition of electrical appliances, the car, etc"
Destroy old or unused medicines
"Discuss health with lay friends, neighbours, relatives"
Do things in moderation
Don't drink
"Don't let things ""get me down"""
Don't smoke
Eat sensibly
Fix broken things around the home straight away
Get enough exercise
Get enough relaxation
Get enough sleep
Have a first aid kit in home
"Ignore health advice from lay friends, neighbours, relatives"
Keep emergency phone numbers near the phone
"Limit foods like sugar, coffee, fats, etc"
Pray or live by the principles of religion
See a dentist for a regular check-up
See a doctor for a regular check-up
Spend free time out of doors
Take vitamins
Use dental floss
Watch one's weight
Wear a seat belt when in a car

Percentage of sample always or almost always performing behaviour (Harris & Guten, 1979)

Behaviour %
Eat sensibly 66
Get enough sleep 66
Keep emergency phone numbers near the phone 65.9
Get enough relaxation 56.4
Have a first aid kit in home 53.1
Destroy old or unused medicines 52.3
See a doctor for a regular check-up 51.1
Pray or live by the principles of religion 47.5
Avoid getting chilled 47.4
Watch one's weight 47
Do things in moderation 46.4
Get enough exercise 46
Avoid parts of the city with a lot of crime 41.2
Don't smoke 41.1
"Check the condition of electrical appliances, the car, etc" 40
"Don't let things ""get me down""" 39.3
Fix broken things around the home straight away 39.2
See a dentist for a regular check-up 36.6
Avoid contact with doctors when feeling okay 35.3
Spend free time out of doors 33.7
Avoid overworking 33
"Limit foods like sugar, coffee, fats, etc" 31.9
Avoid over-the-counter (OTC) medicines 30.2
"Ignore health advice from lay friends, neighbours, relatives" 29
Take vitamins 24.1
Don't drink 24
Wear a seat belt when in a car 22.8
Avoid parts of the city with a lot of pollution 21.5
"Discuss health with lay friends, neighbours, relatives" 17.1
Use dental floss 15.9

 Licensed practical nurses, high school teachers, and college students rated the importance of each of the above behaviours. The nurses considered keeping emergency phone numbers near the phone as the most important behaviour. Teachers considered weight watching as important. Students considered exercise as important. (Turk et al, 1984). Medical students, compared with other students, tend to exercise more, are less likely to smoke, drink alcohol excessively, or take drugs (Golding and Cornish, 1987).

There is little consistency in people’s health behaviour; for example, a person might exercise and also smoke! (E.g. Harris and Guten, 1979).

Three points about health behaviour:

  1. Behaviours can change over time
  2. Health habits are not strongly interdependent
  3. Health behaviours are not governed by a single set of attitudes; you may not smoke because it irritates you, and you might diet because you wish to be attractive.

There are three types of health behaviour

  1. Health behaviour refers to activity that a well person would engage in, in order to prevent illness
  2. Illness behaviour concerns the behaviour someone would engage in, in order to find out what is wrong with him or her and to procure a remedy.
  3. Sick-role behaviour concerns the behaviour a patient engages in, in order to overcome their illness.

Cues in the Environment

Many bad health practices are triggered by cues in the environment, with which the behaviour has been associated with in the past. For example, the sight of an open packet of cigarettes might be enough to trigger the action of lighting up, despite a bad cold. (Hunt et al 1979).

The impact of the family upon children's health behaviour.

Children pick up the good health behaviours (e.g. diet, exercise, not smoking, etc) of other family members.  Modelling and reinforcement play a part in this process. (Baranowski & Nader, 1985).

Sick role behaviour could be determined in the family. A study of female college students accessed whether they had been encouraged during adolescence to adopt the sick role for menstruation or had seen their mothers get upset over menstruation. These women reported more menstrual symptoms, disability and attended clinic more often in adulthood compared with other students (Whitehead et al, 1986).

Concerns of health promotion (Ewles and Simnett, 1992)

The Ottawa Charter for Health Promotion (WHO 1986) identified the following features that it believed were necessary for good health:

·   Peace

·   Shelter

·   Education

·   Food

·   Income

·   A stable ecosystem

·   Sustained resources

·   Social justice

·   Equity

The Yale Model of Communication holds the following specific implications for designing health promotion campaigns:


1.                  It is important that the source of the information is perceived as credible by the audience.

2.       When the audience is positive towards the communicator and the message it is best to use a one-sided argument.

3.                  A low level of fear arousal is necessary in order to trigger perceived threat, but too much fear will cause high levels of tension, leading to avoidance (e.g. Janis and Feshbach 1953).

4.       The message should be short, clear and direct.

5.       The message should be colourful and vivid rather than full of technical terms and statistics.

6.                  If a message is complex, or the audience not very well-informed, then conclusions need to be explicitly stated. Otherwise, it is better to let the audience reach its own conclusions.

7.                  Certain individuals (for example, with low self­esteem) are easier to persuade than others, but they are as likely to be influenced by negative health messages (from advertising and the media) as by health promotion messages.

8.                  If possible, it is best to involve the audience in active participation in the communication process as the effects of the message will last longer.


Fear Appeals

Early study (Lashley & Watson, 1921)

Study of health education films, warning of the risk of VD to First World War soldiers from prostitutes. Films were graphic and had story lines.1 Story line is risky - action followed not the message.


  1. Storylines are too risky as often the story is remembered but not the health message
  2. Must be frank (not flippant) about sex.
  3. Fear arousing effects do not have desired effect. (See recent findings as reported by the BBC)

Baggaley (1991) - media campaigns on AIDS make the above mistakes.

How are attitudes towards condoms related to gender and sexual experiences among adolescents in Finland? (Pötsönen and Kontula (1999)

Janis and Feshbach (1953)

Minimal fear appeal - 36% conformity (evidence based on self-report).
Strong fear appeal - 8% conformity
Illustrated lectures (15 mins) on dangers of tooth decay and need for oral hygiene.

Criticism -

  1. Fear appeals could lead to the person putting up a resistance to the message. The use of an Ego defence mechanism could be an explanation.
  2. Effects are short lived (Leventhal and Hirschman, 1982)
  3. A message needs to tell of appropriate behaviour as well (Leventhal, 1970).
  4. Fear appeals may induce learned helplessness.

The technique of combining the fear message with a self-efficacy message is a common theme in current research, and it appears that the most effective combination is to have a high fear message with a high self-efficacy message (Witte and Allen, 2000). What commonly appears in health education messages, however, is a high fear message with little or no self-efficacy message. A review of messages designed to encourage breast self-examination (BSE) found that the leaflets had an unbalanced proportion of threat to efficacy information. BSE is a technique that women can use to screen themselves for breast cancer, and the alternative screening technique is to use the hi-tech medical procedure called mammography. Interestingly, in the leaflets analysed in the study, the arguments in favour of screening by mammography were very strong, suggesting that there was an underlying aim to encourage the women to seek out medical procedures rather than take control of their own health (Kline and Mattson, 2000).

Learning theory and health behaviour.


If the health behaviour is rewarding then the behaviour is likely to continue. For example, a child might be given a penny for brushing her teeth. An example of a negative reinforcement would be a tablet alleviating a headache.


The taking away of a reward might cause the health behaviour to cease. For example, if the child is no longer given a penny for brushing her teeth, then she might stop; however smiling should prove to be an effective substitute for the money.


If good health behaviour is producing unpleasant side-effects then the behaviour is likely to cease.


Observing others - Bandura (1965).

Coronary Heart Disease


The Three-Community Study

The investigators selected three very similar communities with an average of about 14,000 people in northern California. Two of these towns shared the same TV and radio stations, and were chosen to receive an extensive mass-media campaign. The third town received no campaign and served as a control community because it was relatively distant and isolated from media in the other towns. The media campaign lasted for 2 years and consisted of warnings and information concerning smoking, diet, and exercise. The media included TV, radio, newspapers, posters, and materials sent through the mail.

To evaluate the success of the campaign, the researchers randomly selected several hundred 35- to 59-year-old men and women from each community and interviewed them annually. The large majority of these people completed the entire study, being interviewed before the media campaign began, again after 1year, and then at the end of the campaign. At each interview, the researchers took blood pressure measurements and a sample of blood for analysis; they also assessed the subject's recent health behaviour and knowledge about risk factors for heart disease. After the first interview, the researchers identified over 100 of the subjects in one of the two campaign towns as being at high cardiovascular risk; these individuals also received face-to-face health counselling. The researchers calculated each person's overall risk of cardiovascular disease by combining data on several risk factors, such as age, blood pressure, blood cholesterol levels, weight, smoking behaviour, and so on. The Three Community Study found that people's overall risk increased somewhat in the control community and decreased moderately in the two campaign towns. Face-to-face counselling was particularly effective in getting people to stop smoking.

Coronary heart disease and excessive drinking

Drinking associated with social and cultural norms (Bennett and Murphy, 1994)

In Glasgow, campaign based on safe number of units, replaced with one that concentrated on social costs of drinking too much (Leather, 1981)

CHD and health information

Heart manual (Lewin et al, 1992)

Group given Heart Manual - better psychological adjustment, less visits to GP, less likely to be readmitted to hospital.

Cancer and Breast Self-Examination

BSE effective in early detection of Breast Cancer. Pitts (1991) <30% British women perform BSE

Meyerowitz and Chaiken (1987) the effectiveness of Gain and Loss messages. Gain message worked best. Therefore campaigns should use a positive message.

The BSE instructions are rather complicated. a simpler procedure called `Breast awareness' has been introduced. As the procedure is simpler, women are more confident in being able to carry it out. The procedure produces less false positives. This is when the person falsely identifies a problem, or believes they may be developing breast cancer, when they are not (Murray and McMillan, 1993).


Chip pan fire campaign (Compe 1989)

The campaign produced a 25% reduction in chip pan fires in some areas. 12% reduction overall. Campaigns are most effective if they contain information about what to do rather than what to think or what to be scared of.

Self-Efficacy - If people feel they can carry something out they will. Therefore, if simple actions are required then people will feel more able to follow the advice (e.g. chip pan fires and back to sleep. The message has to be delivered by a credible person. (Zimbardo et al 1977)


Click here for anti-smoking health promotion

Exam question on health promotion

1) Describe a number of studies or approaches to health promotion?
2) Evaluate these studies or approaches
3) Identify an area of   health prevention and suggest how psychology can be
applied to improve the effectiveness of campaigns in this area?

Public health campaigns are being impeded by middle class journalists who ignore diseases that affect the less well off, the health secretary Alan Milburn claimed yesterday.

Explicit ads target sex diseases among young


Harari and Legge (2001) Psychology and Health, Heinemann.  Pages 26 – 30 plus Real Life Application 3 on pages 31 & 32

Philip Banyard, 2002, Psychology in Practice – Health, Hodder & Stoughton, ISBN 0-340-84496-5