Health promotion is defined as "any combination of educational, organizational, economic and environmental supports for behavior and conditions of living conducive to health."1 Health promotion involves the process of enabling people to increase control over and improve their health.It entails a commitment to dealing with the challenges of reducing inequities, extending the scope of prevention and helping people to cope with their circumstances. It also encompasses creating environments conducive to health, in which people are able to take better care of themselves.2
Individual and community health behavior are key components of health promotion. Five levels of influence for health-related behaviors and conditions identified are:
- interpersonal factors such as characteristics of the individual (e.g., knowledge, attitudes, behavior, self concept, and skills);
- intrapersonal or individual factors (formal and informal social network and social support systems, including the family, work group);
- institutional or organiz- ational factors;
- community factors; and
- public policy factors.
Another key idea relates to the possibility of "reciprocal causation" between individuals and their environments, meaning that behavior influences and is influenced by the social environment. Areas of one's lifestyle that health promotion programs address and mediate include, but are not limited to, the following:
- physical activity
- tobacco use
- alcohol-related problems
- drug/substance abuse
- injury, violence, accident prevention
- overweight and obesity
- environmental quality
- responsible sexual behavior (e.g., family planning)
- mental health
- access to health care
- prevention of diseases
Personal factors, such as genetic, physiological, psychological and demographic variables; environmental factors, such as hazards encountered at work, in the community, at home and during recreation; and societal factors, such as cultural and socioeconomic variables, are the base of these problems and also the targets for intervention.
Interventions designed to reduce behavioral risk factors and their consequences can be community-based, work-site-based, based in health care settings, or school-based. Often, the primary care provider works with the patient individually to develop a plan that involves a number of interventions. Of primary importance are behavior change and the initiative on behalf of the patient to take responsibility for his or her own actions and lifestyle behaviors.
Patients must internalize the belief that modifying personal health behaviors will reduce their risk of disease and injury. Making and sustaining changes in health behavior that require acknowledging the need for change is a crucial component. For this reason, patient education and counseling are vital in preventive care and health promotion interventions.
Setting realistic goals, developing workable plans and implementing strategies for timely monitoring of the progress and for making needed changes in the patient's plan are important. Primary care providers should be skilled in how to select and use systems and resources for supporting patients' efforts and working with patients to monitor their progress. There must be a mechanism for follow-up.
Disease prevention, another component of health promotion, encompasses primary, secondary and tertiary prevention. Primary preventive measures involve entirely asymptomatic individuals (e.g., annual routine Pap smear). Secondary preventive measures identify and treat asymptomatic persons who have already developed risk factors or preclinical disease (e.g., obtaining a Pap smear to detect cervical dysplasia).
The scope of health promotion and disease prevention includes the control of communicable diseases, environmental protection, the modification of personal behaviors that affect health, and the prevention and/or reduction of the severity of noncommunicable diseases and chronic disabling conditions.
Health promotion also relates to the individual and/or population's level of health consciousness. There have been some favorable trends in the incidence of death and disability in the United States due to this increased awareness.
Health promotion is a ripe area for research. Social and behavioral research to expand our knowledge of risk-taking and risk-aversive behaviors; prevention of addictive behavior; and motivational factors necessary for adopting health-promoting behaviors are several examples of such research that we can become involved in.
Healthy People 2010 is managed by the Office of Disease Prevention and Health Promotion, a component of the U.S. Department of Health and Human Services. It challenges individuals, communities, and professionals to take specific steps to ensure good health and long life are enjoyed by all. It provides a framework for prevention for the nation. It is a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats.3
The first goal of Healthy People 2010 is to help individuals of all ages increase life expectancy and improve their quality of life. The United States spends more on health care than any other nation. In the year 2000, for example, $690 billion was spent, 40 percent of which was in one's last month of life.
Prevention accounts for only 3 percent of health care expenditures in the U.S. In a chiropractor's practice, health promotion can include helping patients and/or the community to protect the environment, control communicable diseases, modify personal behaviors that affect health and educate patients on how to prevent or reduce the severity of noncommunicable and chronic disabling conditions.
The incidence, morbidity and mortality of certain diseases are disproportionately higher among disadvantaged and minority populations. For example, the life expectancy of a black infant at birth is about seven years less than that of a white infant; the death rate for black infants is nearly double that of whites. The reasons are multifactorial.
One of the most important factors in placing an emphasis on health promotion with your patients is to first assess their readiness. In other words, you want to judge where your patient is in terms of making a decision. There are three steps: First, you want to determine whether a decision to make a health behavior change has actually been made. Ask yourself: Does your patient want to make a decision, or does he or she want you to make the decision? How much time, effort and money is your patient willing to invest in order to attain the goal?
Second, you must closely examine the patient's history. Because of past failures in making health changes or other types of behavior change, the patient may be reluctant to try again. This information should enter into your overall assessment. Ask yourself, for example, if your patient has tried to lose weight, stop smoking or begin an exercise program (whatever behavior change is to be made). Also ask yourself if the patient was successful and for how long. What is the patient's perception of that past effort (reasons for success or failure)? Third, how did the patient come to you for education in the area of health promotion in the first place? Was it by referral, self-referral, etc.?
In summary, health promotion seeks to maximize health by influencing people to make appropriate behavior choices and by creating an environmental context that encourages these choices. We must be cognizant that disparate and disadvantaged populations bring with them a myriad of obstacles (e.g., lack of transportation, lack of resources, not making this a priority) that we must help patients to overcome, enabling them to make a change in behavior. They also may have a "learned helplessness," feeling that it won't matter if they make a change, or they don't know how to make a change, or due to some cultural disparity, they have been accepting disease as a normal way of life, rather than something to be overcome. Readiness is a key component in health promotion. Chiropractors must ask themselves some searching questions to assess their own readiness to confront these issues with patients, and also be ready to assess patients' readiness to get involved in health-promoting changes in their own lives.
The American Public Health Association (APHA) lists health promotion as one of its core values. Chiropractors are encouraged to join the Chiropractic Health Care Section of the APHA to learn more about health promotion and to network with other disciplines involved in promoting health. For more information, visit www.apha.org.
- Green, Prevention and Health Education, 1992.
- Ottawa Charter for Health Promotion, 1990.