Promoting Health

Promoting Health
To Jon and Sara
Commissioning Editor: Mairi McCubbin

Development Editor: Sally Davies
Project Manager: Elouise Ball
Designer: Kirsteen Wright
Illustration Manager: Merlyn Harvey
Promoting Health
A Practical Guide
Angela Scriven BA(Hons) MEd CertEd FRSPH MIUHPE

Reader in Health Promotion, Brunel University, London, UK
Forewords by
Linda Ewles BSc MSc MA
Ina Simnett MA(Oxon) DPhil CertEd
Bristol, UK
Richard Parish BSc Med PDHEd CBiol MIBiol FRSPH FFPH CMIPR HonMAPHA
Chief Executive, Royal Society for Public Health, London, UK
SIXTH EDITION
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Third edition 1995
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
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most current information provided (i) on procedures featured or (ii) by the manufacturer of each
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of administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
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v
Contents
Forewords vii 8 Skills of personal effectiveness 107

Preface xi
Acknowledgements xiii 9 Working effectively with other people 121
PART 1 THINKING ABOUT HEALTH PART 3 DEVELOPING COMPETENCE

AND HEALTH PROMOTION 1 IN HEALTH PROMOTION 131
1 What is health? 3 10 Fundamentals of communication 133
2 What is health promotion? 17 11 Using communication tools in health promotion

practice 147
3 Aims, values and ethical considerations 31
12 Educating for health 163
4 Who promotes health? 45
13 Working with groups 177
PART 2 PLANNING AND MANAGING FOR 14 Enabling healthier living 191

EFFECTIVE PRACTICE 61
15 Working with communities 207
5 Planning and evaluating health promotion 63
16 Influencing and implementing policy 223
6 Identifying health promotion needs
and priorities 77 Glossary 235
7 Evidence and research in health Index 241

promotion 91
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vii
Foreword
We are delighted that Promoting Health is now in its and amalgamated) approached us for an updated
sixth edition. edition.
We embarked on writing the first edition back But the last request for a new edition came at the
in the early 1980s. One of us (Linda Ewles) was stage in our lives when we had both retired from
then working at Bristol Polytechnic (now the Uni- work in health promotion. We felt that the update
versity of the West of England) running one of should be done by someone in closer touch with
the three postgraduate Diploma courses in health current professional thinking and practice. We are
education which existed in the UK at that time. The delighted that Angela Scriven undertook the task
other (Ina Simnett) had recently moved to Bristol and has given the book a new lease of life with a
and was working in health education in the NHS. thoroughly updated version which still retains the
We had each independently recognised the need style and scope of its predecessors. We are very
for a health education textbook; amazing as it grateful to her for her excellent work.
seems now, at the time there were none in the UK. Twenty-five years after the first edition was
We were put in touch with each other by Jane written, we can look back and see that some themes
Randell who did much to develop education and we wrote about then are still totally relevant today.
training at the national Health Education Council. Health promoters still need to explore what ‘health’
It was the start of our long collaboration and means, understand the underlying values and
friendship. approaches in health promotion, think about ethical
We put together an outline of the book’s pro- issues, base their work on evidence of effectiveness
posed content, drawing heavily on our combined and learn skills of communicating and managing,
experience and training. We typed the chapters on planning and evaluating. A surprising amount
a manual typewriter (no word processors then) and of the sixth edition has scarcely changed since the
laboriously looked up all the references in libraries first one.
(no Internet). Our first publisher was John Wiley, But of course a great deal has changed, and this
and Promoting Health: A Practical Guide To Health is reflected in the current edition. We are struck by
Education was launched in May 1985 at a nursing the huge expansion of the evidence base of ‘what
conference in Harrogate. works’ and how much research and information is
We fully expected that the book would have a now available on the Internet. In terms of delivering
shelf life of a few years, and then be superseded by health promotion, the rise of partnership working
many others. Indeed, more textbooks on health between sectors and agencies and the integration of
education and health promotion (when that new health promotion specialist work in the NHS into
term started to be used) did appear – but ours con- mainstream public health (rather than remaining a
tinued to be well used. We had met a need. Every Cinderella ‘add-on’ service) are also remarkable.
few years from then on, our publisher (who changed Health promotion has become an integral part of
several times as publishing companies were sold basic training for health workers and there has
viii Foreword
been a massive growth in specialist training of Asia and the Middle East. We are pleased to think
opportunities. that we must have got something right! We would
Some health education acorns undoubtedly also like to take this opportunity to thank all those
failed to take root, but others have become sturdy people who, in so many different ways, have helped
oak trees. For example, stop-smoking group work to make Promoting Health a success.
by a few health educators has grown into a huge Of course, as Richard Parish points out in his
mainstream NHS smoking cessation programme. Foreword, health promoters now face 21st-century
A handful of health workers going into schools to challenges, such as obesity, alcohol consumption
give talks has developed into a European-wide levels, climate change and new forms of communi-
health-promoting schools network with fully- cable diseases. We hope that this edition continues
fledged personal, social and health education school to contribute to the spread of sound health pro
programmes. motion practice in tackling these and other issues
We are gratified and humbled to think that our which undermine health today. We also hope that
book has made a small contribution to these and it helps people to continue their efforts to reduce
other developments over the last 25 years. It has health inequalities in the UK and across the
been widely used in the UK but also in over 50 world.
countries around the world. It has been translated Linda Ewles
into seven European and Asian languages and has Ina Simnett
been useful in health development in Africa, parts
ix
Foreword
The need for effective health promotion has never The challenge of better health requires action at
been greater. We face immense challenges to health all levels of society. Government and the national
as we move through the 21st century. Regrettably, agencies most certainly have a major role to play,
modern-day life is not always as conducive to not least in supporting those who work to improve
health and wellbeing as we would wish. The current health. The following pages provide an authorita-
scourge of overweight and obesity is but one tive text for everyone involved in promoting health,
measure of our unhealthy lifestyles. To this we must both informing policy makers as to what is possible
add the growing impact of climate change and the and acting as a toolkit for health promoters. From
emergence of new strains of communicable disease. planning and management to monitoring and eval-
Never before have we faced such an assault upon uation, this edition ranges across the full panoply
our health, with the disadvantaged suffering the of tools and techniques. It is genuinely a practical
greatest. guide, helping to ensure effective practice in every
The forces waged against health are complex and area of health promotion work.
comprehensive. We need a skilled and competent Promoting Health: A Practical Guide is not just for
workforce if we are to improve health for all over health promotion specialists responsible for deliv-
the coming years. The earlier editions of Promoting ering better health to the communities with which
Health: A Practical Guide have been heavily used by they work. It also describes the potential for health
students, academic staff in universities and col- promotion. As such, it is an essential tool for com-
leges, policy makers and planners, and by health missioners and those who plan and procure health
promoters going about their everyday work. This improvement services, helping to define how best
new edition will continue the tradition of this to invest public resources.
seminal publication and will strongly influence the Better health will only be achieved through
training of future practitioners. Building on its rich actions at all levels of society. The state and the
pedigree, this latest edition tackles the major health public sector, commercial organisations, voluntary
issues facing us today, focusing on practical inter- agencies and individual citizens all have a role to
ventions for better health. play. This book will help ensure effective and effi-
Many strategies and techniques in health promo- cient action. We must deploy our resources to
tion are tried and tested. There is a sound and maximum advantage, for the cost of not doing so
growing evidence base. We know what works in will be measured in avoidable ill health, unneces-
most situations, although we must be ever vigilant sary expenditure and a loss of human potential. To
in pursuing new approaches and evaluating the this end Promoting Health: A Practical Guide is a valu-
outcomes. Effective health promotion draws on able investment.
many disciplines, adapting to the emergence of new Richard Parish
evidence. This book reflects contemporary think-
ing, referring to the application of new technologies
and approaches such as social marketing.
xi
Preface
The aim of this book is to provide an accessible ● Who needs health promotion and what are
practical guide for all those who practise health these needs?
promotion in their everyday work. It was first pub- ● How can priorities be set?
lished in 1985, and in response to demand a new ● How can health promotion be planned,
updated edition has been produced approximately managed and evaluated?
every five years. Earlier editions have also been ● How can health promoters best carry out health
published in German, Hungarian, Finnish, Greek, promotion? What are the competencies they
Indonesian, Italian and Swedish. require?
The book is addressed to all those who promote
● What are the key issues for health promotion?
health, including health promotion and public
health practitioners and specialists, hospital and There is a focus on the theories, principles and com-
community nurses, health visitors and midwives, petencies you need to consider, whatever your
hospital doctors and general practitioners, dentists background and wherever you work. The range of
and dental hygienists, pharmacists, health service health issues and settings for health promotion
managers and the professions allied to medicine. It (such as communities, schools, workplaces, GP
is also for the wide range of health promoters in surgeries or hospitals) is clearly enormous, but it
statutory and non-statutory agencies, for example is beyond the scope of this book to cover all these
local authority staff such as environmental health in depth. Different professional groups will all
officers and social workers, voluntary organisa- have their own areas of expert knowledge and spe-
tions, youth and community workers, teachers in cialist skills to be employed alongside the specific
schools, colleges and universities, probation offic- expertise in promoting health addressed in this
ers, prison officers and police officers. book.
Health promotion encompasses a wide variety of As in previous editions, the book is organised
activities, with the common purpose of improving into three parts. Part 1 Thinking About Health and
the health of individuals and communities. This Health Promotion deals with basic ideas of what
book is concerned with the what, why, who and health, health promotion and health education are
how of health promotion. It aims to help you about, and the different approaches and ethical
explore important questions such as: issues that need to be considered, and identifies the
agencies and people who have a part to play in
● What is health?
health promotion and public health.
● What affects health? Part 2 Planning and Managing for Effective Practice
● What is health promotion? How is it part of a looks at planning and evaluation at the level of a
wider public health movement? health promoter’s daily work and starts by intro-
● Who are the agents and agencies of health ducing a basic planning and evaluation framework.
promotion? It continues with a discussion of how to identify
xii Preface
and assess needs and priorities, and develop skills website addresses, to reflect the increased use of the
to manage yourself and your work effectively. internet to disseminate health information and evi-
Part 3 Developing Competence in Health Promotion dence, with such networking sites as Twitter and
looks at how you can develop your competence in YouTube being used in a health-promoting capac-
carrying out a range of activities, including en ity by the Department of Health, non-governmental
abling people to learn in one-to-one and group set- organisations and community health groups.
tings, enabling people towards healthier living, Non-sexist writing is used throughout the text,
working with communities and changing policies drawing on the ideas on non-sexist writing dis-
and practices. The fundamentals of communi cussed in Chapter 11. Several terms have been
cation and of using communication tools are also used to describe the people that health promotion
addressed. targets. These terms include ‘patients’ (referring
This sixth edition is fully revised and updated to mainly to those who receive their health promotion
take account of recent developments in public in a healthcare environment), ‘clients’ (for patients
health, such as revised national strategies for health, and non patients) or simply users, individuals or
reorganisations that have taken place in the National groups. The term ‘health promoters’ is used to
Health Service, and new policies that have a bearing cover the multidisciplinary workforces that have
on the promotion of health. It is important to note, remits for promoting health, but whose job titles
however, that policies and strategies for health fre- cover a wide spectrum, including public health
quently change, particularly when governments practitioners (see Ch. 2 for a discussion on who
change, and there will be a general election during promotes health).
the life of this sixth edition. It is likely, therefore, The overall aim of the book is the same as in
that some of the policies referred to in the text may previous editions, to keep you involved, so that
have been replaced. New issues that are highlighted studying this book will be an active educational
are: experience. Exercises are included to undertake as
● changes to the structure and organisation of the an individual or in a group, and examples and case
National Health Service in the UK studies are provided to help you to apply ideas
● national standards for work in health
to your own situation. Often the exercises are
promotion and public health designed to stimulate thought and discussion and
there may be no right answers. You will need to
● new research on the comparative effectiveness
think it through, talk it over and reflect. In this way
of different approaches to health promotion
the answers will have personal meaning and
● reference to new technology, especially the
application.
Internet London, 2010 Angela Scriven
● new approaches, including social marketing.
The user-friendly style adopted in the previous
editions has been retained. There are many more
xiii
Acknowledgements
Linda Ewles and Ina Simnett, the authors of the first elements of the book have been strongly influenced
five editions of this book, produced a seminal text by the work of others. Many of these remain and
that I and many others have used in the training have been further adjusted to suit the current needs
and education of health promoters over the last 25 of health promoters. Finally, I would like to thank
years. Their book has shaped health promotion Professor Richard Parish for his Foreword, and for
practice in the UK over this time. I am privileged to their support and encouragement throughout the
have been invited to take over the authorship and process of producing this new edition, Sally Davies
wish to thank Ewles and Simnett and Elsevier, the and Mairi McCubbin from Elsevier, my colleague
publishers, for giving me this opportunity. I also Sebastian Garman at Brunel University and my
wish to thank all of those who had an involvement family and friends.
in the first five editions. Some of the exercises and
15
PART 1
Thinking about health and

health promotion
Part Contents
1. What is health? 3
2. What is health promotion? 17
3. Aims, values and ethical considerations 31
4. Who promotes health? 45
Part Summary
Part 1 has three purposes: There is also an historical overview of some of the
● It sets the context for the whole book, by international and national movements that have
introducing key concepts, principles and ideas worked towards better health.
and by providing you with a common language in In Chapter 2 health promotion is defined and shown
which to communicate about health promotion. to encompass a wide range of activities. Frameworks
● It offers an introduction to the dimensions and
are given for classifying the major areas of health
scope of health and health promotion, which enables promotion action. Occupational standards are outlined
you to focus on the wide range of activities and and an exercise is provided to help you to explore the
approaches being utilised by health promoters. scope of your health promotion work.
In Chapter 3 the aims and values associated with
● It highlights important philosophical and ethical
different approaches to health promotion are analysed,
issues, which are explored in a practical context
a number of ethical dilemmas are examined and guid-
later in the book.
ance is provided on how to make ethical decisions.
Health is an extremely difficult word to define but it is In Chapter 4 the agents and agencies of health
clearly important that you know what it means. This is promotion are identified and there is an opportunity to
discussed in Chapter 1, along with a description of the clarify your own health promotion role.
major influences on health and inequalities in health.
3
Chapter 1
What is health?
Summary
Chapter Contents
This chapter starts with an exercise which enables
What does being healthy mean to you? 3 you to examine what being healthy means to you,
and reviews the wide variation in people’s concepts of
Concepts of health 4
health. Dimensions of health are considered (physical,
What affects health? 7 mental, emotional, social, spiritual and societal)
and health is explored as a holistic concept. Factors
Improving health – historical overview 10
that affect health are identified, with a particular
International initiatives for improving health 11 focus on medicine and inequalities in health. Case
studies illustrate the factors that shape the health of
National initiatives 12
people in differing circumstances. In the final section
Where are we now? 13 there is a historical overview of the contribution of
international and national movements towards better
health.
What Does Being Healthy Mean

to You?
Being healthy means different things to different

people, and much has been researched and written
about people’s varying concepts of health (see, for
example, Hughner & Kleine 2004 and Earle 2007).
It is fundamental that you, as a health promoter,
explore and define for yourself what being healthy
means to you and what it may mean to your clients.
This is the aim of Exercise 1.1.
Exercise 1.1 generally shows that different people
identify different aspects of being healthy as impor-
tant. What you choose is often a reflection of your
particular circumstances at the time, your experi-
ences and/or your professional background. For
example, if you are feeling stressed at work you
may consider enjoying work without too much
4 Promoting Health: A Practical Guide
EXERCISE 1.1 What does being healthy mean to you?

In Column 1, tick any of the statements that seem to you to be important aspects of your health. Tick as many as you
like.
For me, being healthy involves: Column 1 Column 2 Column 3
1. Enjoying being with my family and friends ■ ■ ■
2. Living to a ripe old age ■ ■ ■
3. Feeling happy most of the time ■ ■ ■
4. Having a job ■ ■ ■
5. Hardly ever taking tablets or medicines ■ ■ ■
6. Being the ideal weight for my height ■ ■ ■
7. Taking regular exercise ■ ■ ■
8. Feeling at peace with myself ■ ■ ■
9. Never smoking ■ ■ ■
10. Never suffering from anything more serious than a mild cold, ■ ■ ■
flu or stomach upset
11. Not getting things confused or out of proportion – assessing ■ ■ ■
situations realistically
12. Being able to adapt easily to big changes in my life such as ■ ■ ■
moving house or a new job
13. Drinking only moderate amounts of alcohol or none at all ■ ■ ■
14. Enjoying my work without too much stress ■ ■ ■
15. Having all the parts of my body in good working condition ■ ■ ■
16. Getting on well with other people most of the time ■ ■ ■
17. Eating the ‘right’ foods ■ ■ ■
18. Enjoying some form of relaxation or recreation ■ ■ ■
In Column 2, tick the six statements which are the most important aspects of ‘being healthy’ to you.
Then in Column 3, rank these six in the order of importance – put 1 by the most important, 2 by the next most
important and so on down to 6.
If you are working in a group, compare your list with other people’s. Look at the similarities and differences, and
discuss the reasons for your choices.
(Adapted with kind permission from Open University 1980.)
stress as important, or if you work in a smoking Lay Perceptions

cessation service you may prioritise not smoking as
a crucial aspect of being healthy. As your circum- It is important to understand the way lay people
stances change, your idea of what being healthy think about health and wellness, as this influ
means to you is also likely to change. ences their health and wellness-related behaviours
(Hughner & Kleine 2004). Researchers have found
a wealth of complex lay notions about health. Some
Concepts of Health lay perceptions are based on pragmatism, where
health is regarded as a relative phenomenon, expe-
As Exercise 1.1 will have indicated, health is a dif- rienced and evaluated according to what an indi-
ficult concept to define in absolute terms. The vidual finds reasonable to expect, given their age,
meaning can be culturally and professionally deter- medical condition and social situation. For them
mined and has changed over time (Thomas 2003). being healthy may just mean not having a health
A variety of definitions and explanations of what it problem which interferes with their everyday lives
means to be healthy exists (Duncan 2007) and none (Bury 2005). Thomas (2003) has classified some
can be deemed to be right or wrong. personal constructs of health into models. The
Chapter 1 What is health? 5
functional model, for example, is based on social role Because of this variety and complexity of the
performance and social normality, rather than ways in which people conceptualise health, it is
physical normality; the psychological model empha- difficult to measure health.
sises the ability to deal with stress and having resil- For more about measuring health, see Chapter 6,
ience. Whatever the lay understandings of health section on finding and using information.
are based on, however, they illustrate that lay
accounts are unique, and health and strategies for
health must be individualised. For example: Professional Concepts of Health
● Homeless, single young people in Scotland Professional concepts of health have changed
viewed their health in terms of functional over time. In the late 19th and 20th century, as
concepts such as taking regular exercise and medical discoveries were made and medical prac-
getting a good night’s sleep. In this respect, tice developed, there was a preoccupation with a
health was seen as a tool for everyday living mechanistic view of the body and consequently
(Watts et al 2006). with physical health. Earlier still, there have been
● Lay men’s understanding of health and centuries of many philosophies of health in differ-
wellbeing has been shown in a study to relate ent civilisations, such as Greek and Chinese, where
to notions of control, and the associated issues a more holistic view of health has been held. See
of risk and responsibility. Specifically, men saw Lloyd & Sivin (2002) for a comparison of these two
health in more psychological terms (Robertson cultures and their view on health, science and
2006). medicine.
● Exploration of children’s concepts of health has One way of understanding the various meanings
shown that their ideas of being healthy and that the different professional groups hold is to
what makes them healthy are strongly tied up put health into broad categories or models. Three
with notions of infection; health for them is the models are identified below and include the medical
lack of symptoms like a cough or running nose. model, the holistic model, and the wellness model.
Children in the study also linked
environmental pollution with health, with The medical model
smoking seen as an environmental pollutant, ● The medical model dominated thinking about
but did not mention violence, being homeless health for most of the 20th century.
or similar social factors among health ● Health is defined and measured as the absence
determinants (Piko & Bak 2006). of disease and the presence of high levels of
function.
Concepts of health, illness and disease have gener-
● In its most extreme form, the medical model
ally been linked with people’s social and cultural
situations. Knowledge of illness, prevention and views the body as a machine, to be fixed when
treatment can also be powerful in shaping people’s broken.
concept of health. Such knowledge may be part of ● It emphasises treating specific physical
a cultural heritage, passed on through generations diseases, does not accommodate mental or
(Kue Young 2005). social problems well and de-emphasises
Standards of what may be considered healthy prevention.
also vary. An elderly woman may say she is in good
health on a day when her chronic arthritis has The holistic model
eased up enough to enable her to get to the shops. ● The holistic model was exemplified by the
A man who smokes may not regard his early World Health Organization (WHO) constitution
morning cough as a symptom of ill health, because which referred to health as a state of complete
to him it is normal. People assess their own health physical, mental and social wellbeing and not
subjectively, according to their own norms and merely the absence of disease or infirmity
expectations. (WHO 1948).
People may also trade-off different aspects of ● This broadened the medical model perspective,
health. A common example is that people may and highlighted the idea of positive health,
accept the physical health damage from smoking as although the WHO did not originally use that
the price they pay for the emotional benefit. term, and linked health to wellbeing.
● The WHO definition is in many ways difficult that these conceptions run the risk of excessive
to measure. This is less because of the breadth, of incorporating all of life. Thus, they do
complexity of measuring wellbeing, as not distinguish clearly between the state of being
psychologists have done (for example White healthy and the consequences of being healthy; nor
2007), but more because doing so required do they distinguish between health and the deter-
subjective assessments that contrast sharply minants of health (some of the above is adjusted
with the objective indicators favoured by the from http://courseweb.edteched.uottawa.ca).
medical model. It is important to note that the WHO (1948)
constitution definition of health mentioned above
The wellness model has been heavily criticised, mainly on two grounds:
● In 1984, a WHO discussion document
it is unrealistic and idealistic and it implies a
proposed moving away from viewing health static position. A study by Jadad & O’Grady (2008)
as a state, toward a dynamic model that found that some criticisms of the WHO definition
presented it as a process or a force (WHO focused on its lack of operational value and the
1984). This was amplified in the Ottawa Charter problem created by use of the word ‘complete’. An
for Health Promotion which proposed that health extreme critique, such as Smith (2008), call it a ludi-
is the extent to which an individual or group is crous definition that would leave most of us
able to realise aspirations and satisfy needs, unhealthy most of the time. In support of the defi
and to change or cope with the environment. nition, Jadad & O’Grady (2008) argue that the
Health is seen as a resource for everyday life, WHO invited nations to expand the conceptual
not the objective of living; it is a positive framework of their health systems beyond the tra-
concept, emphasising social and personal ditional boundaries set by the physical condition of
resources, as well as physical capacities individuals and their diseases, and it challenged
(WHO 1986). political, community and professional organisa-
● Related to this is the notion of resiliency, such tions devoted to improving or preserving health to
as the success with which individuals and pay more attention to the social determinants of
communities adapt to changing circumstances health.
(see Antonovsky 1979 and 1987, and his Sense Even just using these three broad categories of
of Coherence theory). health, it follows that there will be differences
There are advantages and disadvantages to each of between health practitioners’ concepts of health. To
these models. The advantage of the medical model take one example, practitioners of complementary
is that disease represents a major public health issue medicine hold to a range of beliefs about what
facing society, and disease states need to be treated health is and how health can be restored or
and can be readily diagnosed and counted. But improved which is based on holism and em
this approach is narrow, negative and reductionist, powerment (Barrett et al 2004).
and in an extreme form implies that people with In exploring the concept of health further it is
disabilities are unhealthy, and that health is only useful to consider the identification of different
about the absence of morbidity. A further potential dimensions of health which began with the WHO
limitation to the medical model is its omission of a definition but have been subsequently expanded.
time dimension. Should we consider as equally The dimensions now include:
healthy two people in equal functional status, one Physical health. This is perhaps the most obvious
of whom is carrying a fatal gene that may lead to dimension of health, and is concerned with the
early death? mechanistic functioning of the body.
The holistic and wellness models have the advan- Mental health. Mental health refers to the ability
tage of allowing for mental as well as physical to think clearly and coherently. It can be distin-
health, and on broader issues of active participation guished from emotional and social health, although
in life. They also allow for more subtle discrimina- there is a close association between the three.
tion of people who succeed in living productive Emotional health. This means the ability to recog-
lives despite a physical impairment. The visually nise emotions such as fear, joy, grief and anger and
impaired or amputees, for example, may still be to express such emotions appropriately. Emotional
able to satisfy aspirations, be productive, happy (or affective) health also means coping with stress,
and so be viewed as healthy. The disadvantage is tension, depression and anxiety.
Social health. Social health means the ability to capacities, not simply the absence of disease (WHO
make and maintain relationships with other people. 1984).
Spiritual health. For some people, spiritual health This is a rich view of health. It encompasses
might be connected with religious beliefs and prac- ideas of:
tices; for other people it might be associated with ● Personal growth and development (‘realise
personal creeds, principles of behaviour and ways aspirations’).
of achieving peace of mind and being at peace with ● Meeting personal basic needs (‘satisfy needs’).
oneself.
● The ability to adapt to environmental changes
Societal health. So far, health has been considered
(resilience to change and cope with the
at the level of the individual, but a person’s health
environment’).
is inextricably related to everything surrounding
● A means to an end, not an end in itself (a
that person. It is impossible to be healthy in a sick
society that does not provide the resources for basic resource for everyday life, not the objective of
physical and emotional needs. For example, people living).
obviously cannot be healthy if they cannot afford ● Not just absence of disease (a positive concept).
necessities like food, clothing and shelter, but ● A holistic concept (social and personal
neither can they be healthy in countries of extreme resources … physical capacities).
political oppression where basic human rights This notion of health has much to offer the health
are denied. Women cannot be healthy when promoter. It recognises that health is a dynamic
their contribution to society is undervalued, and state, that a person’s potential is different, and that
neither black nor white can be healthy in a racist each person’s health needs vary. Working for health
society where racism undermines human worth, is both an individual and a societal responsibility,
self-esteem and social relationships. Unemployed and involves empowering people to improve their
people cannot be healthy in a society that values quality of life.
only people in paid employment, and it is very This discussion of health as a concept is an
unlikely that anyone can be healthy if they live in important prerequisite to thinking about what
an area that lacks basic services and facilities such determines people’s health. Before moving on to a
as health care, transport and recreation. consideration of what affects health, it might be
The identification of these different aspects of useful to undertake Exercise 1.2 and to read Case
health is a useful exercise in raising awareness of studies 1.1 and 1.2 and answer the associated
the complexity and the holistic nature of health. But questions.
in practice it is obvious that dividing people’s
health into categories such as physical and mental
can impose artificial divisions and unhelpful distor- What Affects Health?
tions. Sexual health, for example, can cross all these
boundaries proving that the dimensions of health Being healthy is rarely, if ever, the result of chance
are interrelated. or luck. A state of health or ill health, however
Some writers have provided useful analyses of defined, is the result of a combination of factors
what health means from different disciplinary per- having a particular effect on a particular individual
spectives. Seedhouse (2001), for example, proposes at any one time. In order to work towards better
the idea of health as the foundation for achieving a health, we need to identify these influential factors.
person’s realistic potential. You can begin by identifying factors that influence
Similarly, when the WHO broadened their defi- your own health, using Exercise 1.3.
nition, as noted in the wellness model outlined Exercise 1.3 will have identified a huge range of
earlier in the chapter, they also identified key factors which affect health. They are likely to include
aspects of health. The conception of health is the genetic make-up, gender, family, religion, culture,
extent to which an individual or group is able to friends, income, advertising, social life, social class,
realise aspirations and satisfy needs, to change or race, age, employment status, working conditions,
cope with the environment, where health is seen health services, self-esteem, self-confidence, access
as a resource for everyday life, not the objective to leisure facilities and shops, housing, education,
of living; it is a positive concept emphasising national food policy, environmental pollution and
social and personal resources, as well as physical many more.
EXERCISE 1.2 Dimensions of health EXERCISE 1.3 What affects your health?
1. Go back to your answers in Exercise 1.1 ‘What The aim of this radiating circle exercise is to identify
does being healthy mean to you?’ Tick if any of factors that affect your health. The exercise can be
the following dimensions of health are reflected in done:
the statements you ticked in Column 1: ■ individually
■ individually, followed by comparing results with
Physical ■ Emotional ■
Mental Spiritual other people
■ ■
■ as a group, pooling your ideas about what
Social ■ Societal ■
influences your health.
Is any one of these dimensions more important to You are at the centre of the rings:
you than the others? How do they relate to each In the inner ring, write in factors that influence your
other? health and that are to do with yourself as an individual.
2. Has your idea of health changed since childhood? In the second ring, write in factors that influence
If so, how and why? How do you think your idea your health and that are to do with your immediate
of health may change as you grow older? social and physical environment.
3. If you have had professional training in health or In the outer ring, write in factors that influence your
a related area of work, what difference has this health and that are to do with your wider social,
made to your idea of health? physical or political environment.
4. What do you think being healthy may mean to
someone who: Outer ring
 has learning difficulties?
 has a permanent physical disability such as
deafness or paralysis? Second ring
 has an illness or infection for which there is
currently no known cure such as diabetes,
arthritis, HIV, schizophrenia? Inner ring
 lives in poverty?
5. Identify three or four key points you have learnt
from this exercise about your own ideas of being
healthy.
YOU
Health and Medicine

There has been much debate since the 1970s about
the relative importance of the many and varied
determinants of health. There have also been con-
cerns that medicine might have less effect on the How do these factors influence your health –
population’s overall health improvement than pro- positively or negatively?
moting lifestyle changes or social reforms, although Which factors do you think are the most important?
some have argued that these concerns are not Are there factors that you have not identified for
founded (see, for example, Bunker 2001). The yourself, but which may be important for other people?
National Health Service (NHS) has undoubtedly
(Burkitt 1982, reproduced with kind permission of Medical
evolved in the main as a treatment and care service
Education (International) Ltd.)
for people who are ill, not as the major means of
improving public health (Baggott 2004, Klein 2006
and Ham 2009 offer further discussion of the NHS
and healthcare policies).
Some people have claimed that the practice of
scientific medicine has, in fact, done considerable
harm. Examples are the side-effects of treatment,
complications that set in after surgery and depend-
CASE STUDIES 1.1 AND 1.2 What shapes people’s health and health beliefs?
Case 1.1 Salma to have a second mastectomy and more
Salma had been widowed twice, and now believes chemotherapy. She is a primary school teacher and
that people are plotting against her. At the same has just returned to work part time. She loves her
time, she is in a desperate situation, living with her work and has very supportive colleagues. She was
four children in a small, crumbling, two-bedroomed divorced 2 years after the first mastectomy and now
terraced house. She has no money for repairs, and no lives alone with her daughter, Charlie. Anne has lots
husband to support her or help put things right. The of friends, a large extended family and a good social
rooms are poorly decorated and the emersion heater network. She feels healthy and is determined to
is broken so there is only cold water in the bathroom. overcome the cancer and has established a new diet
To have a bath, Salma has to heat water on the and exercise programme to help her stay healthy. Like
cooker downstairs and carry it up. The plumbing needs her parents, she wants to live to a very old age, and
repair, and there is no water in the cold water tap of looks forward to Charlie being settled in life and to
the washbasin. Salma sleeps with her daughter in one having grandchildren. She belongs to a cancer support
of the bedrooms and her three sons sleep in the other. group and is planning to undertake a half marathon
One of the downstairs rooms cannot be used because to raise money for a cancer charity. While Charlie
it needs replastering, and the floor boards are admires her mother and the way she is dealing with
dangerous in another. Salma applied for a repair grant her illness, she is worried that she may die of cancer
about a year and a half ago. They came and took soon. Charlie is in her final year of university and
pictures and didn’t do anything about it. She has also while she considers herself to be fit and healthy, since
applied for a council house, but she has been told it she became a student she smokes heavily, frequently
will take a long time. She feels there is nothing wrong binge drinks, and when she is very stressed will
with her health; just nerves. She feels like her life is occasionally use drugs. She often has casual and
being squeezed out of her. She worries about her sometimes unprotected sex when drunk. Her diet is
children. They cannot play outside or go to the park not good; she either skips meals or just eats take-
because the English children fight with them, and the away foods. She knows that her chances of getting
house is too small and dangerous to play in. breast cancer are higher because her mother has had
■ What affects the health of Salma and her children? it, so feels she should enjoy life to the full while she
■ What is Salma’s own view about her health? Why is young. She found her parents’ divorce very difficult
do you think she holds this view? and hasn’t seen her father in 5 years. She has been
■ What should be done to improve and promote the very depressed over the past 6 months but has
health of Salma and her children? (Adjusted from continued with her university degree because she
Commission for Racial Equality 1993.) knows her mother would be very upset if she
withdraws.
Case 1.2 Anne and Charlie ■ What affects the health of Anne and Charlie?
Anne is 57 years old and has cancer. She had it for ■ What are Anne’s and Charlie’s own views about
the first time 7 years ago, when a lump was their health? Why do you think they hold these
discovered when she went along to her first views?
mammography, and she had a mastectomy. Six ■ What could be done to improve and promote the
months ago another lump was discovered and she had health of Anne and Charlie?
ence on prescribed drugs. But more important, best, a treatment and care service for the ill and, at
perhaps, is that control over health and illness has worst, a means of undermining people’s compe-
been taken away from people themselves, who tence and confidence to improve their health
become dependent on doctors and medical drugs. reached a peak around 1980, led in part by the work
Aspects of life that are natural, such as pregnancy of Illich (1977), but they are still relevant today (see,
and childbirth, the menopause and ageing, have for example, Jackson 2001 and Meyer 2001). There
become medicalised and the responsibility for are moves to change this perception of the health
health has shifted from the lay public to the medical services and government policy is currently in place
profession. These arguments that medicine is, at to attempt to make the healthcare services fairer,
more personalised, effective and safe (Department levels of trust and many networks for the exchange
of Health (DoH) 2007a). of information, ideas and practical help. Social
capital is produced when, for example, there are
neighbourhood schemes of child care and crime
The Wider Determinants of Health
prevention, community groups and social activities
The Black Report (Townsend & Davidson 1982) that engage a wide range of interests and people
showed that, for almost every kind of illness and (Li 2007).
disability in the UK, people in the upper socio Differences in health experience may not be due
economic groups had a greater chance of avoiding entirely to socioeconomic determinants. There are
illness and staying healthy than those in the lower important differences in rates of illness and death
socioeconomic groups. It also established the differ- between ethnic groups, which may be related to
ences in the risks to men and women, and varia- differences in income, education and living condi-
tions in the apparent health consequences of living tions, cultural factors or genetic make-up. There are
in different parts of the country. also differences associated with age, sex, occupa-
All this pointed to the fact that the major deter- tion and where people live (Wilkinson & Marmot
minants of health were socioeconomic conditions, 2003). Addressing the distribution of wealth in
geographical location and gender. Evidence from society, reducing the gap between rich and poor
the late 1990s (Acheson 1998) demonstrated that the and tackling socioeconomic disadvantage are
health gap was widening, so that while overall clearly political issues (DoH 2003), and the post-
population health may be improving, the rate of 2010 strategic review of health inequalities (the
improvement is not equal across all sections of Marmot Review) demonstrates the government’s
society. The gap in the health status between the continued commitment to reducing health
lower socioeconomic groups and the higher socio- inequalites.
economic groups continues to increase.
Work comparing data across different countries
has shown another slant on the issue of inequalities. Improving Health – Historical
It is not the richest societies that have the best Overview
health, but those that have the smallest income dif-
ferences between rich and poor. It is the relative A number of conclusions can be drawn from the
difference in income levels which is crucial. The discussion above. First, health is a complex concept,
reason seems to be that small income differences meaning different things to different people.
across society mean an egalitarian society that has Second, health status is linked with people’s ability
a strong community life and better quality of life in to reach their full potential. Finally, health is affected
terms of strong social networks, less social stress, by a wide range of factors, which may be broadly
higher self-esteem, less depression and anxiety and classified as:
more sense of control (Marmot 2005). All of this
● Lifestyle factors to do with individual health
adds up to better health.
In recent years the UK government has imple- behaviour.
mented a programme of action to tackle health ● Broader social, economic and environmental
inequalities (see DoH 2007b for a status report on factors such as whether people live in an
the strategies in place). At the time of writing the egalitarian society, what social support
government has also commissioned a post-2010 networks are available, and how they live in
strategic review of health inequalities (the Marmot terms of employment, income and housing.
Review; see References). It will be interesting to Early public health work in the first half of the
monitor whether the Marmot Review will repeat 20th century concentrated on structural reforms
the findings of earlier reports, or whether the review such as slum clearance, improved sanitation and
will show that the Programme for Action set in place clean air. Then in the 1950s and 1960s the focus
(DoH 2003) has been effective. shifted towards the need for changes in individual
One way of addressing health inequalities and health behaviour, for example, family planning,
inequities is by building social capital. Social capital venereal disease (the original term to describe
is the term used to describe investment in the social sexually transmitted infections), accident preven-
fabric of society, so that communities develop high tion, immunisation, cervical smear checks, weight
control, alcohol consumption and smoking. This This regional strategy called for fundamental
emphasis on the lifestyle approach meant a con changes in the health policy of member countries,
centration of effort on health education, which was including a much higher priority for health promo-
reflected in government statements at the time tion and disease prevention. It called for not only
(see, for example, Department of Health and Social health services but all public sectors with a poten-
Security 1976). Over time, this emphasis has been tial impact on health to take positive steps to main-
heavily criticised because it distracts attention from tain and improve health. Specific regional targets
the social and economic determinants of health, were published; these have been subsequently
and tended to blame individuals for their own ill updated and the movement is now called Health
health. For example, people with heart disease 21 (WHO 1999a, b). The targets emphasised the
could be blamed for it because they were over- following HFA principles:
weight and smoked, but the reasons for being over-
● Reducing inequalities in health.
weight and smoking, what Marmot (2005) refers
● Positive health through health promotion and
to as the causes of the causes, were ignored. Reasons
disease prevention.
may have included lack of education, no help avail-
able to stop smoking, eating and smoking used as ● Community participation.
a way of coping with stresses such as poor housing ● Cooperation between health authorities, local
or unemployment, lack of availability of cheap authorities and others with an impact on
nutritious foods, and so on. This blaming people health.
for their health behaviour became known as victim- ● A focus on primary health care as the main
blaming (see Dougherty (1993) and Caraher (1995) basis of the healthcare system.
for early discussions of victim-blaming). In the The Health for All targets for Europe, which
1980s a broader approach was used in conjunction European governments and the WHO aimed to
with what was called the new public health move- reach by 2000, were reviewed and evaluated at the
ment (WHO 1986). It encompassed health educa- end of the century (http://www.euro.who.int).
tion but also political and social action to address Progress had been made on many fronts, but targets
issues such as poverty, employment, discrimina- had not been reached, mainly because of political,
tion and the environment in which people live. social and economic difficulties.
It also, importantly, focused on the grass-roots Health 21 sets out 21 targets for the European
involvement of people in shaping their own health region. The targets cover a wide range, including
destiny. reducing health inequalities. Target 2 states: ‘By the
See Chapter 4 for information on people and year 2020, the health gap between socioeconomic
organisations working to improve public health. groups within countries should be reduced by at
least one fourth in all Member States, by substan-
tially improving the level of health of disadvan-
International Initiatives for taged groups’ (WHO 1999b). Other Health 21 targets
Improving Health cover better health for children and older people;
reducing communicable and chronic diseases, inju-
More is said about the role of the WHO and other ries and harm from alcohol, drugs and tobacco;
international organisations in Chapter 4. developing better health care, policies and strate-
gies for health; and partnership working.
The WHO took a leading role in the evolution of
A major milestone for health promotion was the
health promotion in the 1980s and 1990s. It stated
publication in 1986 of the Ottawa Charter, launched
in 1978 that the main target of governments in the
at the first WHO international conference on
coming decades should be the attainment of all
health promotion held in Ottawa, Canada (WHO
citizens of the world by the year 2000 of a level of
1986). This identified five key themes for health
health that will permit them to lead a socially and
promotion:
economically productive life (WHO 1978). This was
the beginning of what came to be known as the 1. Building a healthy public policy.
Health for All (HFA) movement. It led to the devel- 2. Creating supportive environments.
opment of a strategy for the WHO European Region 3. Developing personal skills through information
in 1980 (WHO 1985). and education in health and life skills.
4. Strengthening community action. health improvement. The first was The Health of the
5. Reorienting health services towards prevention Nation in England (DoH 1992), and comparable
and health promotion. strategies for Wales, Scotland and Northern Ireland.
(See Scriven & Speller (2007) for an overview of the These were the first national strategies to focus on
global influence of Ottawa.) health and health gain rather than illness and health
The Jakarta declaration in 1997 (WHO 1997) re services.
iterated the importance of the Ottawa Charter prin- The most recent of these strategies are:
ciples and added priorities for health promotion ● 2001: the National Assembly for Wales (NAW)
in the 21st century: published Improving Health in Wales: a
● Promote social responsibility for health. Summary Plan for the NHS with its Partners
● Increase investment for health development. (NAW 2001a) and an action plan Promoting
● Expand partnerships for health promotion. Health and Wellbeing: Implementing the
● Increase community capacity and empower the
National Health Promotion Strategy (NAW
individual. 2001b).
● 2002: in Northern Ireland the Department of
● Secure an infrastructure for health promotion.
Health and Social Services and Public Safety
The Bangkok Charter for Health in a Globalized World (DHSSPS) published Investing for Health: a
is the most recent WHO declaration (WHO 2005). Public Health Strategy for Northern Ireland
The Charter builds on Ottawa by asserting that (DHSSPS 2002).
progress towards a healthier world requires strong
● 2003: the Scottish Office (SO) published
political action, broad participation and sustained
Improving Health in Scotland: the Challenge
advocacy.
(SO 2003).
The call is to ensure that health promotion’s
● 2004: in England the Department of Health
established repertoire of proven effective strategies
will need to be fully utilised, with all sectors and published Choosing Health: Making Healthy
settings acting to: Choices Easier (DoH 2004).
● advocate for health based on human rights and A further significant development was that in
solidarity 2001 the Department of Health published national
● invest in sustainable policies, actions and targets to reduce inequalities in England, and re
infrastructure to address the determinants of affirmed these in 2007 as part of the spending
health review. This welcome emphasis on reducing ine-
● build capacity for policy development, qualities ensures that work to improve the health
leadership, health promotion practice, knowledge of the public will have inequalities in health at its
transfer and research, and health literacy core, at both local and national levels. The targets
● regulate and legislate to ensure a high level of are as follows:
protection from harm and enable equal ● Starting with children under 1 year, by 2010 to
opportunity for health and wellbeing for all reduce by at least 10% the gap in mortality
people between routine and manual groups and the
● partner and build alliances with public, population as a whole.
private, nongovernmental and international ● Starting with local authorities, by 2010 to
organizations and civil society to create reduce by at least 10% the gap in life
sustainable actions. expectancy between the fifth of areas with the
worst health and deprivation indicators (the
National Initiatives Spearhead Group) and the population as a
whole (http://www.dh.gov.uk).
See Chapter 7, section on national health strategies, for
Also in 2001, a long-awaited report was produced
more about national strategies for health and how they
by the Chief Medical Officer, setting out the role for
are implemented.
a stronger public health function and building
An important development for the UK in the early on targets set in national health strategies (DoH
1990s was the advent of national strategies for 2001). The report identified major themes relevant
to achieving a stronger public health function, economic groups in the UK (DoH 2007b, 2009).
including: Health promoters in the UK are still faced with
● a wider understanding of health entrenched inequality in health status, and huge
problems of poverty, unemployment and home-
● a better and more coordinated public health
lessness (Marmot 2005). This raises questions about
function
the distribution of wealth in society and emphasises
● partnership working
that health is a political issue.
● community development and public
involvement
● an increased and more capable public health PRACTICE POINTS
workforce ■ Health and being healthy mean different things to
● increased health protection. different people, and you need to explore and
understand what they mean to you and to your
clients.
Where Are We Now? ■ A wide range of factors at many levels influence
and determine people’s health.
It is clear from the above that there is a broad under- ■ There are wide inequalities in the health status of
standing of the wider determinants of people’s people from different social classes, ethnic groups,
health, and there are international and national age groups, sexes and people who live in different
health strategies which are reviewed and revised on geographical locations.
an ongoing basis. There is a stronger national and ■ Improving people’s health means addressing the
local emphasis on prevention, health improvement social, environmental and economic factors that
and reducing inequalities, with health promotion affect their health, as well as individual health
playing a bigger part in the role of all the health and behaviour and lifestyle.
social welfare professions. Health issues feature ■ International and national strategies and
more in public policy debate at both central and movements have emerged to tackle the lifestyle,
local government and in the health service. socioeconomic and environmental determinants of
But as yet these positive developments have health, and to reduce inequalities in health.
failed to narrow the health gap between socio
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17
Chapter 2
What is health promotion?
Summary
Chapter Contents
This chapter starts with a discussion of the definitions
Defining health promotion 17 of health promotion, and the related terms health
gain, health improvement, health development, health
Health gain, health improvement and health
education and social marketing. This is followed by
development 18
an examination of the position of health promotion
Health education, health promotion and social within the multidisciplinary public health movement.
marketing 18 An outline of the scope of health promotion work is
offered, with frameworks for activities for promoting
Multidisciplinary public health 19
health. Broad areas of practice covered by professional
Involvement in public health 20 health promoters and the core competencies needed
are set out with an outline of the framework for
The scope of health promotion 20
national occupational standards. Exercises are included
A framework for health promotion activities 24 to help you explore the range of health promotion
Broad areas of competencies important to health activities and the extent of your own health
promotion practice 25 promotion work.
Occupational standards in health promotion 26
Defining Health Promotion
Health promotion is about raising the health status

of individuals and communities. Promotion in the
health context means improving, advancing, sup-
porting, encouraging and placing health higher on
personal and public agendas.
Given that major socioeconomic determinants of
health are often outside individual or even collec-
tive control, a fundamental aspect of health promo-
tion is that it aims to empower people to have more
control over aspects of their lives that affect their
health.
These twin elements of improving health and
having more control over it are fundamental to the
aims and processes of health promotion. The World
Health Organization (WHO) definition of health

promotion as it appears in the Ottawa Charter has Health needs
been widely adopted and neatly encompasses this: assessment
‘Health promotion is the process of enabling people (Where are we now?)
to increase control over, and to improve, their
health’ (WHO 1986).
Decide priorities
Health Gain, Health Improvement Evaluation
and set targets
and Health Development (How well are we doing?
How far have we got?) (Where do we want
to get to?)
Health development, health improvement and
health gain are terms that are also employed
when discussing the process of working to improve
people’s health. Health development is defined as Make agreements
the process of continuous, progressive improve- and commission health
ment of health status of individuals and groups in services and programmes
a population (Nutbeam 1998). The Jakarta Declara- (Specifying how we will
get there)
tion (WHO 1997) describes health promotion as an
essential element of health development. Health
Fig. 2.1 The health gain cycle.
improvement is frequently used by national
health agencies. For example, there is a health
improvement section on the Department of
Health (DoH) website (http://www.dh.gov.uk)
and NHS Scotland calls itself Scotland’s health smoking has been effective when so many influ-
improvement agency (http://www.healthscotland. ences can affect smoking habits?
com). A research study undertaken by Abbott An intervention means a planned activity
(2002), however, found that people’s understand- designed to improve health. It could be treatment,
ing of health improvement varied and ranged from a care service or a health promotion activity.
explaining the term primarily as a government The role of health promoters in assessing health
strategy – as a set of activities for the NHS – or in needs, deciding on priorities, setting objectives and
terms of the overarching purpose of health improve- targets, allocating resources, and monitoring and
ment. One definition sees health improvement reviewing outcomes can be seen as a health gain
as covering a wide range of activity, principally cycle (Fig. 2.1). Health gain is a useful concept. It
focused on improving the health and wellbeing of focuses attention on health outcomes and on how
individuals and communities (so much like health different choices or priorities can be compared by
promotion) (http://www.suffolkcoastal.gov.uk). considering the extent to which they contribute to
The term health gain emerged in policy docu- health gains for individuals or groups.
ments in the late 1980s (for example, Welsh Health
Planning Forum 1989). One useful early definition
said health gain was a measurable improvement in Health Education, Health
health status, in an individual or population, attrib- Promotion and Social Marketing
utable to earlier intervention (Nutbeam 1998).
Measurable means that it should be possible to The WHO (1998) defined health education as the
put a value, usually a numerical value, onto health consciously constructed opportunities for learning
status, in order to demonstrate that a change has involving some form of communication designed
occurred. to improve health literacy, including improving
Attributable means proving that the change in knowledge, and developing life skills which are
health status is the result of the intervention. This conducive to individual and community health (see
can be difficult. How will you be certain, for Smith et al 2006 for updates on the WHO glossary
example, that a specific programme to reduce of health promotion terms). In the 1970s the range
Chapter 2 What is health promotion? 19
of activities undertaken in the pursuit of better organised efforts of society. The Faculty of Public
health began to diverge from health education Health (FPH) also uses this definition but offers
(Scriven 2005). There was also criticism that the guidelines specifying that public health:
health education approach was too narrow, focused ● Is population based.
too much on individual lifestyle and could become ● Emphasises collective responsibility for health,
victim-blaming (see Ch. 1, Improving Health – its protection and disease prevention.
Historical Overview) and increasingly work was
● Recognises the key role of the state, linked to a
being undertaken on wider issues such as political
concern for the underlying socioeconomic and
action to change public policies. Such activities
wider determinants of health, as well as
went beyond the scope of traditional health
disease.
education.
● Emphasises partnerships with all those who
Health promotion as a term was used for the
first time in the mid 1970s (Lalonde 1974) and contribute to the health of the population
quickly became an umbrella term for a wide range (http://www.fphm.org.uk).
of strategies designed to tackle the wider determi- Three spheres of public health have been outlined
nants of health. There is no clear, widely adopted by Griffiths et al (2005):
consensus of what is meant by health promotion
(see Scriven 2005 for a detailed discussion of Health improvement
the development and use of the term). Some defini- ● Inequalities
tions focus on activities, others on values and prin- ● Education
ciples. The WHO (1986) definition defines health ● Housing
promotion as a process but implies an aim (enabling ● Employment
people to increase control over, and improve, ● Family/community
their health) with a clear philosophical basis of ● Lifestyles
self-empowerment.
● Surveillance and monitoring of specific diseases
Recently in the UK, health-related social market-
and risk factors.
ing has emerged as a prominent health promoting
strategy to achieve and sustain behaviour goals on
Improving services
a range of social issues. There are a number of defi-
● Clinical effectiveness
nitions of social marketing, but the description most
generally in use is the systematic application of ● Efficiency
marketing, alongside other concepts and tech- ● Service planning
niques, to achieve specific behavioural goals, for a ● Audit and evaluation
social good and to improve health and reduce ine- ● Clinical governance
qualities (French & Blair-Stevens 2005). The exact ● Equity.
relationship between social marketing and health
promotion is currently being debated, so there is no Health protection
consensus on whether social marketing comes ● Infectious diseases
under the health promotion umbrella of approaches ● Chemicals and poisons
to health gain.
● Radiation
● Emergency response
Multidisciplinary Public Health ● Environmental health hazards.
It is clear from these definitions and explanations
In the last decade, national and local policy has that public health requires a wide range of comp
focused on the development of multidisciplinary etencies (Evans & Dowling 2002), that it is a multi-
public health (see Berridge 2007 for a critique and disciplinary activity involving people from many
overview of these developments). Public health professions and backgrounds (DoH 2001, Coen &
work has been defined by Acheson (DoH 1998) as Wills 2007) and that health promotion activities
the science and art of preventing disease, pro overlap with and are an integral part of the UK
longing life and promoting health through the public health function (DoH 2005).
Involvement in Public Health The Scope of Health Promotion
See also Chapter 1, section on national initiatives, for The questions in Exercise 2.1 give examples of the
more about this report. wide range of activities that may be classified as
health promotion. Answering ‘yes’ to each one indi-
There are three levels of involvement in public
cates a broad view of what may be included: mass
health (DoH 2001):
media advertising, campaigning on health issues,
1. Teachers, social workers, voluntary sector staff patient education, self-help, environmental safety
and health workers all have a role in health measures, public policy issues, health education,
improvement. They need to adopt a public preventive and curative medical procedures, codes
health mind set and appreciate how their work of practice on health issues, health-enhancing facili-
can make a difference to health and wellbeing, ties in local communities, workplace health policies
and where more specialist support can be and social education for young people. Answering
obtained locally. ‘no’ indicates that you identify criteria that you
2. A smaller number of hands-on public health believe exclude these activities from the realms of
professionals, such as health visitors and health promotion. For example, you may have said
environmental health officers, who spend a ‘no’ to Item 2 because increasing tobacco taxation
major part, or all, of their time in public health would place a heavier burden on smokers in poor
practice working with communities and groups. financial circumstances, thus putting their health
3. A still smaller group of public health specialists even more at risk.
from medical and other professional Attempts to provide frameworks and models
backgrounds, who work at a senior level with for classifying activities have helped to clarify the
responsibility to manage strategic change and scope of health promotion (see Naidoo & Wills 2000
lead public health initiatives. This group for an overview). Drawing on these, Fig. 2.2 identi-
includes health promotion specialists and fies the activities that contribute to health gain and
medically qualified public health doctors. maps out all those activities which aim to improve
people’s health. There are two sets of activities,
The roles of professionals who contribute to health those about providing services for people who are
promotion work are discussed in Chapter 4. ill or who have disabilities, and positive health
EXERCISE 2.1 Exploring the scope of health promotion

Consider each of the following activities and decide whether you think each is, or is not, health promotion:
Yes No
1. Using TV advertisements to encourage people to be more physically active.  
2. Campaigning for increased tax on tobacco.  
3. Explaining to patients how to carry out their doctor’s advice.  
4. Setting up a self-help group for people who have been sexually abused as children.  
5. Providing schools with a crossing patrol to help children across the road outside schools.  
6. Raising awareness of how poverty affects health.  
7. Giving people information about the way their bodies work.  
8. Immunising children against infectious diseases such as measles.  
9. Protesting about a breach in the voluntary code of practice for alcohol advertising.  
10. Running low-cost gentle exercise classes for older people at local leisure centres.  
11. Providing healthier menu choices at workplace canteens.  
12. Teaching a programme of personal and social education in a secondary school.  
13. Providing support to people with learning disabilities living in the community.  
14. Using social marketing tools to ensure behavioural change in a group of smokers.  
What were your reasons for saying ‘yes’ or ‘no’? Can you identify the criteria you are using for deciding whether an
activity is ‘health promotion’?
Personal Health
social services care services
ILLNESS AND
DISABILITY
SERVICES
HEALT H G A IIN
N
Health
Preventive
education
health services
programmes
Social Community-based
marketing POSITIVE work
HEALTH
ACTIVITIES
Economic
Organisational
and regulatory
development
activities
Environmental Healthy
health measures public policies
Fig. 2.2 Activities for health gain.
activities, which are about personal, social and Healthcare services. This includes the major work
environmental changes aiming to prevent ill health of the health services: treatment, cure and care in
and develop healthier living conditions and life- primary care and hospital settings.
styles. These two sets of activities overlap, because An important question when considering the
they both contribute to health gain, and they are boundaries of service provision by health promot-
often closely related in practice. Ten categories of ers is: ‘If all illness and disability services improve
activities are identified, comprising two illness and health and produce varying amounts of health gain,
disability services and eight types of positive health are they all called health promotion?’ For example,
activities. is taking out someone’s appendix or placing a child
in a foster home health promotion?
It is helpful to go back to the WHO (1986) defini-
Illness and Disability Services
tion of health promotion, about enabling people to
Personal social services. This includes all those increase control over and improve their health.
social services aimed at addressing the needs of sick Things that need to be done to people (like taking
people and people with disabilities or disadvan- out their appendix or placing them in foster homes)
tages whose health (in its widest sense) is improved are excluded from this definition, so are generally
by those services. This includes, for example, com- not considered to be health promotion activities
munity care of mentally ill people and home help (although they are health gain activities). But those
services for the elderly. aspects of care and treatment that are about
enabling people to take control over their health secondary health education, educating patients
and improve it (such as educating patients in the about their condition and what to do about it.
skills of self-care, or educating foster parents in the Restoring good health may involve the patient in
skills of parenting) are legitimate areas of health changing behaviour (such as stopping smoking) or
promotion. So is creating a health promoting envi- in complying with a therapeutic regime and, pos-
ronment by, for example, modifying a home to sibly, learning about self-care and self-help. Clearly,
make it suitable for a person with disabilities or health education of the patient is of great impor-
providing affordable housing for homeless people tance if treatment and therapy are to be effective
with health problems. and illness is not to recur.
Tertiary health education. There are, of course,
many patients whose ill health has not been, or
Positive Health Activities
could not be, prevented and who cannot be com-
pletely cured. There are also people with perma-
Health education programmes nent disabilities. Tertiary health education is
These are planned opportunities for people to learn concerned with educating patients and their carers
about health, and to undertake voluntary changes about how to make the most of the remaining
in their behaviour. Such programmes may include potential for healthy living, and how to avoid
providing information, exploring values and atti- unnecessary hardships, restrictions and complica-
tudes, making health decisions and acquiring skills tions. Rehabilitation programmes contain a consid-
to enable behaviour change to take place. They erable amount of tertiary health education with a
involve developing self-esteem and self-empower- focus on improving quality of life.
ment so that people are enabled to take action about Quantenary health education. This concentrates on
their health. This can happen on a personal one-to- facilitating optimal states of empowerment and
one level such as health visitor/client, teacher/ emotional, social and physical wellbeing during a
pupil, or in a group such as a smoking cessation terminal stage (see Hancock 2001, Scriven 2005).
group or exercise class, or reach large population It is not always easy to see where people fit into
groups through the mass media, health fairs or this primary, secondary or tertiary framework
exhibitions. because a person’s state of health is open to inter-
pretation. For example, is educating an overweight
See Chapters 10–14 for detailed information on carrying
person who appears to be perfectly well, despite
out these health promotion activities.
being overweight, primary or secondary health
Health education programmes may also be a education?
part of healthcare and personal social services, and
because of this it is useful to understand the con-
cepts of primary, secondary and tertiary health
Social marketing
education. The National Social Marketing Centre (NSMC)
Primary health education. This would reflect identifies the primary aim of health-related social
McKinley’s (1979) vision of upstream, preventative marketing as the achievement of a social good
activity. It is directed at healthy people, and aims to (rather than commercial benefit) in terms of
prevent ill health arising. Most health education for specific, achievable and manageable behaviour
children and young people falls into this category, goals, relevant to improving health and reducing
dealing with such topics as sexual health, nutrition health inequalities. Social marketing is a systematic
and social skills and personal relationships, and process using a range of marketing techniques and
aiming to build up a positive sense of self-worth in approaches (a marketing mix) phased to address
children. Primary health education is concerned not short-, medium- and long-term issues. The follow-
merely with helping to prevent illness but with ing six features and concepts are pertinent to under-
positive wellbeing. standing social marketing:
Secondary health education. There is also often a Customer or consumer orientation. A strong cus-
major role for health education when people are ill. tomer orientation with importance attached to
It may be possible to prevent ill health moving to a understanding where the customer is starting from,
chronic or irreversible stage, and to restore people their knowledge, attitudes and beliefs, along with
to their former state of health. This is known as the social context in which they live and work.
Behaviour and behavioural goals. Clear focus on to examine in more detail the links between social
understanding existing behaviour and key influ- marketing and health promotion, see NSMC (2008).
ences upon it, alongside developing clear behav-
ioural goals. These can be divided into actionable
and measurable steps or stages, phased over time.
Preventive health services
Intervention mix and marketing mix. Using a mix of These include medical services that aim to prevent
different interventions or methods to achieve a par- ill health, such as immunisation, family planning
ticular behavioural goal. When used at the strategic and personal health checks, as well as wider pre-
level this is commonly referred to as the interven- ventive health services such as child protection
tion mix, and when used operationally it is described services for children at risk of abuse.
as the marketing mix.
Audience segmentation. Clarity of audience focus
using audience segmentation to target effectively.
Community-based work
Exchange. Use of the exchange concept, under- This is a bottom-up approach to health promotion,
standing what is being expected of people, and the working with and for people, involving communi-
real cost to them. ties in health work such as local campaigns for
Competition. This means understanding factors better facilities. It includes community develop-
that impact on people and that compete for their ment, which is essentially about communities iden-
attention and time (adjusted from http://www. tifying their own health needs and taking action to
nsmcentre.org.uk). address them. The sort of activities that may result
Social marketing uses the total process planning could include forming self-help and pressure
model summarised in Fig. 2.3. The front end scoping groups, and developing local health-enhancing
stage drives the whole process. The primary concern facilities and services.
is establishing clear actionable and measurable
See Chapter 15, Working with communities.
behaviour goals to ensure focused development
across the rest of the process. The ultimate effective-
ness and success of social marketing rests on Organisational development
whether it is possible to demonstrate direct impact
This is about developing and implementing policies
on behaviour. It is this feature that sets it apart
within organisations to promote the health of staff
from other communication or awareness raising
and customers. Examples include implementing
approaches, such as health education, where the
policies on equal opportunities, providing healthy
main focus is on imparting information and ena-
food choices at places of work and working with
bling people to understand and use it. The informa-
commercial organisations to develop and promote
tion on social marketing above has been adjusted
healthier products.
from the NSMC website (http://www.nsmcentre.
org.uk). For more details on how to engage in See Chapter 16, Influencing and implementing policy.
health-related social marketing, see Macdowall
et al (2006) and NSMC (2007). To explore the effec-
Healthy public policies
tiveness of social marketing as an approach, see
McDermott et al (2005) and Stead et al (2007), and Developing and implementing healthy public poli-
cies involves statutory and voluntary agencies, pro-
fessionals and the public working together to
develop changes in the conditions of living. It is
about seeing the implications for health in policies
about, for example, equal opportunities, housing,
Scope Develop Implement Evaluate Follow-up
employment, transport and leisure. Good public
transport, for example, would improve health by
reducing the number of cars on the road, decreasing
pollution, using less fuel and reducing the stress of
the daily grind of travelling for commuters. It could
Fig. 2.3 Social marketing uses a total process planning also reduce isolation for those who do not own cars
model. (NSMC and Consumer Focus 2007. Reproduced with permission). and enable people to have access to shopping and
leisure facilities, all measures that improve well in Fig. 2.4. The first is that activities do not always
being (See Scriven 2007 for a detailed overview of fall neatly into categories. For example, would a
healthy public policies). health visitor who was supporting a local women’s
health group be engaged in a health education pro-
See Chapter 16, Influencing and implementing policy.
gramme because they provided health information
to the group and set up stress management ses-
Environmental health measures sions, or in community-based work because some
Environmental health is about making the physical members of the group had got together to lobby
environment conducive to health, whether at home, their local health services for better sexual health
at work or in public places. It includes public health advice clinics for young people?
measures such as ensuring clean food and water Obviously areas of activity overlap, but this is
and controlling traffic and other pollution. not important. What is important is to appreciate
the range of activities encompassed by health pro-
motion, and the many ways in which you can con-
Economic and regulatory activities tribute to health improvements.
These are political and educational activities The second point about using this framework
directed at politicians, policy makers and planners, is to note that it reflects planned, deliberate activi-
involving lobbying for and implementing legisla- ties, and it is important to recognise that a great
tive changes such as food labelling regulations, deal of health promotion happens informally and
pressing for voluntary codes of practice such as incidentally. For example, portrayal of damage
those relating to alcohol advertising or advocating caused by excessive drinking on television soaps
financial measures such as increases in tobacco and an advertising campaign to promote whole-
taxation. wheat breakfast cereals are all health promotion
activities which are not likely to be planned with
specific health promotion aims in mind. They may,
A Framework for Health however, be significant influences for change.
Promotion Activities
See Chapter 11, section on mass media.
There are two important points to make about the Exercise 2.2 is designed to help you to identify
use of the framework of health promotion activities your own contribution to health promotion.
Health education Preventive

(primary, secondary health services
and tertiary
Social Community-based
marketing work
AREAS OF
HEALTH PROMOTION
ACTIVITIES
Economic
Organisational
and regulatory
development
activities
Environmental Healthy
health measures public policies
Fig. 2.4 A framework for health promotion activities.

high level of competence is needed in one-to-one

EXERCISE 2.2 Identifying your health promotion
work communication and in working with groups in
various ways, both formal and informal.
Look at Fig. 2.4 again, which identifies eight major areas Effective communication is an educational com-
of health promotion activity. By each of the eight petence, but health promoters also need to under-
headings, note down any parts of your work you think stand how people receive information and learn.
come into that category. If you are not sure what each For example, patient education requires communi-
category includes, look back at the explanations. Then cation and educational competencies.
think about each category again, and consider whether
there is scope for developing your work within each
category. Marketing and publicising
Marketing and publicising are addressed in Chapter 11.
This requires competence in, for example, market-

ing and advertising, using local radio and getting
Broad Areas of Competencies local press coverage of health issues. It may be used
Important to Health when undertaking any health promotion activities
Promotion Practice that would benefit from wider publicity.
In order to engage in the activities outlined in the
framework in Fig. 2.4, health promoters require a Facilitating, networking,
range of competencies. There are two aspects of partnership working
work to consider. One is the technical/specialist
This means enabling others to promote their own
aspect such as immunising a child, taking a cervical
and other people’s health, using various means
smear test, recording blood pressure or undertak-
such as sharing skills and information and building
ing microbiological tests for food hygiene purposes.
up confidence and trust. These competencies are
All of these are the subject of specialist training, and
particularly important when working with commu-
outside the scope of this book.
nities. They are also vital for working with other
The other aspect of your work is about working
agencies and forming partnerships for health that
with people to promote health in many different
cross barriers of organisations and disciplines.
situations with a variety of different aims. To do
this, health promoters need to have knowledge of Facilitating, networking and partnership working are
particular methods and acquire specialist compe- addressed in Chapters 9, 13 and 15.
tencies in the following areas:
Influencing policy and practice
Managing, planning and evaluating Health promoters are in the business of influencing
All these are addressed in Part 2: Planning and policies and practices that affect health. These can
managing for effective practice, Chapters 5–9. be at any level, from national (such as policies set
by government or political parties about, for
Managing resources for health promotion, includ-
example, housing, transport and future directions
ing money, materials, oneself and other people, is
for the NHS) to the level of day-to-day work of a
crucial. Systematic planning is needed for effective
health promoter (such as what sort of health pro-
and efficient health promotion. All health promo-
motion programmes will be run in a GP practice, or
tion work also requires evaluation, and different
what resources will be devoted to specific health
methods are appropriate for different approaches.
promotion activities in an environmental health
department).
Communicating and educating Influencing policy and practice is addressed in Chapter 16.
Communication and educating are addressed in Chapters
In order to influence policy and practice, you
8–14.
need to understand how power is distributed and
Health promotion is about people, so competence exercised between people at any level, from a group
in communication is essential and fundamental. A of colleagues to those in positions of great authority
or influence. You need to be able to use that know competencies for health promotion. Currently in
ledge to affect decisions. This includes working the UK competencies set out in the form of occupa-
with statutory, voluntary and commercial organisational standards are available for specialists and
tions to influence them to develop health promot- practitioners in public health (Skills for Health
ing policies for their staff and to produce health 2007). There is currently no agreed route through
enhancing products and services. It also includes these standards for health promotion specialists or
working for healthy public policies and economic practitioners.
and regulatory changes requiring lobbying and At an international level, the Galway Con
taking political action. sensus Statement (http://www.sophe.org; see also
It is unrealistic to expect all health promoters to Morales et al 2009) sets out eight domains of core
be highly competent in all aspects of health promo- competency in health promotion. They are: catalys-
tion. Practice nurses, for example, will work pre- ing change, leadership, assessment, planning,
dominantly in health education and preventive implementation, evaluation, advocacy and partner-
health services, needing a high level of competence ships. At the time of writing there is broad consulta-
in communication and education. However, they tion on the consensus statement, so it will be
also needs other competencies in order to plan and interesting to monitor the development of both UK
evaluate their work, market health promotion pro- and international health promotion competency
grammes to their patients, facilitate change in their statements over the coming years.
patients and be able to refer them to a network of The standards developed for specialist practice
helpful contacts. They will also need to be able to in public health set out in Box 2.1 are applicable (at
influence the development of health promotion least in part) to health promotion. It is useful to
policy in their practice. examine these standards and to think about the
areas of health promotion work you are involved in
and which standards are important for your work.
Occupational Standards in It is also important to recognise the areas you do
Health Promotion not use in your work and to think about the implica-
tions for working collaboratively with other pro
At the time of writing there are a number of differ- fessionals. Exercise 2.3 is designed to encourage
ent initiatives taking place in the UK and in Europe you to think about your health promotion work and
that will result in a much clearer set of core how it contributes to the wider public health
BOX 2.1 Overview of the national standards for public health (Skills for Health 2007)
Area 1: Surveillance and assessment of the 6. Collect, structure and analyse data on the health
population’s health and wellbeing – see Chapter 6 and wellbeing and related needs for a defined
population.
1. Collect and form data and information about health
7. Undertake surveillance and assessment of the
and wellbeing and/or stressors to health and
population’s health and wellbeing.
wellbeing.
2. Obtain and link data and information about health
Area 2: Promoting and protecting the population’s
and wellbeing and/or stressors to health and
health and wellbeing – see Chapters 5–7 and 16
wellbeing.
3. Analyse and interpret data and information about 1. Communicate with individuals, groups and
health and wellbeing and/or stressors to health and communities about promoting their health and
wellbeing. wellbeing.
4. Communicate and disseminate data and information 2. Encourage behavioural change in people and
about health and wellbeing and/or stressors to agencies to promote health and wellbeing.
health and wellbeing. 3. Work in partnership with others to promote health
5. Facilitate others’ collection, analysis, interpretation, and wellbeing and reduce risks within settings.
communication and use of data and information 4. Work in partnership with others to prevent the
about health and wellbeing and/or stressors to onset of adverse effects on health and wellbeing in
health and wellbeing. populations.
Continued
BOX 2.1 Overview of the national standards for public health (Skills for Health 2007) – cont’d
5. Work in partnership with others to contact, assess Area 6: Policy and strategy development and
and support individuals in populations who are at implementation to improve health and wellbeing
risk from identified hazards to health and wellbeing. – see Chapter 16
6. Work in partnership with others to protect the
1. Work in partnership with others to plan, implement,
public’s health and wellbeing from specific risks.
monitor and review strategies to improve health
7. Promote and protect the population’s health and
and wellbeing.
wellbeing.
2. Work in partnership with others to assess the
Area 3: Developing quality and risk management impact of policies and strategies on health and
within an evaluative culture – see Chapter 7 wellbeing.
3. Work in partnership with others to develop policies
1. Develop one’s own knowledge and practice.
to improve health and wellbeing.
2. Contribute to the development of the knowledge
4. Appraise policies and recommend changes to
and practice of others.
improve health and wellbeing.
3. Support and challenge workers on specific aspects
5. Improve health and wellbeing through policy and
of their practice.
strategy development and implementation.
4. Manage the performance of teams and individuals.
5. Contribute to improvements at work.
Area 7: Working with and for communities to
6. Develop quality and risk management within an
improve health and wellbeing – see Chapter 15
evaluative culture.
1. Facilitate the development of people and learning in
Area 4: Collaborative working for health and communities.
wellbeing – see Chapters 4 and 9–14 2. Create opportunities for learning from practice and
1. Build relationships within and with communities experience.
and organisations. 3. Support communities to plan and take collective
2. Develop, sustain and evaluate collaborative work action.
with others. 4. Facilitate the development of community groups/
3. Represent one’s own agency at other agencies’ networks.
meetings. 5. Enable people to address issues related to health
4. Work in partnership with communities to improve and wellbeing.
their health and wellbeing. 6. Enable people to improve others’ health and
5. Enable the views of groups and communities to be wellbeing.
heard through advocating on their behalf. 7. Work with individuals and others to minimise the
6. Provide information and advice to the media about effects of specific health conditions.
health and wellbeing and related issues. 8. Improve health and wellbeing through working with
7. Improve health and wellbeing through working and for communities.
collaboratively.
Area 8: Strategic leadership for health and
Area 5: Developing health programmes and services wellbeing – see Chapters 8 and 13
and reducing inequalities – see Chapters 5–8
1. Use leadership skills to improve health and
1. Work in partnership with others to plan, implement wellbeing.
and review programmes and projects to improve 2. Promote the value of, and need for, health and
health and wellbeing. wellbeing.
2. Manage change in organisational activities. 3. Lead the work of teams and individuals to achieve
3. Develop people’s skills and roles within community objectives.
groups/networks. 4. Design learning programmes.
4. Assess, negotiate and secure sources of funding. 5. Enable learning through presentations.
5. Develop health programmes and services and reduce 6. Evaluate and improve learning and development
inequalities. programmes.
Continued
BOX 2.1 Overview of the national standards for public health (Skills for Health 2007) – cont’d
7. Strategically lead the improvement of health and 6. Improve health and wellbeing through research and
wellbeing and the reduction of inequalities. development.
Area 9: Research and development to improve Area 10: Ethically managing self, people and
health and wellbeing – see Chapter 7 resources to improve health and wellbeing –
see Chapters 3 and 5–9
1. Plan, undertake, evaluate and disseminate research
and development about improving health and 1. Promote people’s equality, diversity and rights.
wellbeing. 2. Prioritise and manage own work and the focus of
2. Develop and maintain a strategic overview of activities.
developments in knowledge and practice. 3. Manage the use of financial resources.
3. Develop, implement and evaluate strategies to 4. Monitor and review progress with learners.
advance knowledge and practice. 5. Facilitate individual learning and development
4. Commission, monitor and evaluate projects to through mentoring.
advance knowledge and practice. 6. Enable individual learning through coaching.
5. Contribute to the evaluation and implementation of 7. Ethically manage self, people and resources to
research and development outcomes. improve health and wellbeing.
EXERCISE 2.3 Mapping your health promotion work against the standards for specialist practice in
public health
Study the areas identified as specialist public health practice and tick the level of activity you are involved in. Look at
Box 2.1 for details of the work covered by each area of activity.
Note the areas you work in and the areas that are outside your current job responsibilities or which you are not
trained to do.
Compare this mapping with that of colleagues or other health workers.
Very high
level of High level Fair level Some level No activity
Area of public health practice activity of activity of activity of activity in this area
Area 1: Surveillance and assessment of the     
population’s health and wellbeing.
Area 2: Promoting and protecting the population’s     
health and wellbeing.
Area 3: Developing quality and risk management     
within an evaluative culture.
Area 4: Collaborative working for health and     
wellbeing.
Area 5: Developing health programmes and     
services and reducing inequalities.
Area 6: Policy and strategy development and     
implementation to improve health and
wellbeing.
Area 7: Working with and for communities to     
improve heath and wellbeing.
Area 8: Strategic leadership for health.     
Area 9: Research and development.     
Area 10: Ethically managing self, people and     
resources.
Standards taken from Skills for Health (2007)
function. It will also help you to think about the performance, identifying their learning needs
differences between health promotion and public and defining the learning outcomes needed to
health. meet the national standards.
3. Education and training providers can use the
Using the National standards to modify their programmes to
Occupational Standards enable practitioners to develop appropriate
competencies, or use the standards as the basis
Broadly speaking there are three uses for the of their programme design.
national occupational standards:
1. Employers and managers can use the standards
to improve the quality of the performance of PRACTICE POINTS
their staff. An organisation can map what it is ■ Health promotion practice encompasses a wide
trying to achieve against the areas and sub- range of approaches that are united by the same
areas of practice. It can then look at its service goal, to enable people to increase control over and
specifications and its management of human improve their health.
resources through job specifications, staff ■ It is important for you to identify the full scope of
appraisal and performance review. The your health promotion work and to see how this fits
standards could also be used as the basis for with the work of your organisation or employer and
auditing a service and checking whether it the wider remit of public health.
meets quality standards. ■ The national standards for specialist practice in
Audit is discussed in more detail in Chapter 7. public health provide a map which can be used by
organisations, managers, education and training
2. Individuals can use the standards to improve providers, and individuals to improve the quality of
their competence through identifying their key public health and health promotion work.
areas of work, assessing their own
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31
Chapter 3
Aims, values and ethical considerations
Summary
Chapter Contents
In this chapter some key philosophical issues about
Clarifying health promotion aims 32 aims and values in health promotion practice will be
identified and explored. Two fundamental dilemmas
Analysing your aims and values:
about the aims of health promotion will be addressed.
five approaches 34
First, whether health promoters should aim to change
Ethical dilemmas 36 the individual or to change society, and second,
whether they should set out to ensure compliance
Making ethical decisions 40
with a health promotion programme or to enable
Towards a code of practice 41 clients to make an informed choice. A framework of
five approaches to health promotion is provided as
a tool for analysing key aims and values, along with
exercises and case studies. Ethical issues are discussed,
four ethical principles are described and there is a
series of questions designed to help health promoters
to make ethical choices. Exercises on making ethical
decisions are included.
This chapter establishes some of the key philosoph-

ical issues in health promotion. You are encouraged
to think deeply about why you are engaging in
specific activities, what values are reflected in your
work and what ethical dilemmas are presented.
Guidelines on how to approach ethical decision
making are considered and some key principles of
practice are explored.
Philosophical issues are fundamental to practice,
but as Seedhouse (2004) argues, the values of health
promotion are sometimes muddled. Health promo-
tion work, if successful, will influence the lives of
individuals and communities and it would be irre-
sponsible to develop and apply health promotion
practical skills without understanding the values
and ethics that should underpin health promotion ● There is a danger of imposing alien or
interventions. opposing values. For example, a doctor may
perceive that the most important thing for a
patient’s physical health is to lose weight and
Clarifying Health Promotion Aims cut down on alcohol consumption, but drinking
beer in the pub with friends may be far more
Should health promoters aim to change individual important in terms of overall wellbeing to the
behaviour and lifestyles or aim to influence the overweight, middle-aged, unemployed patient.
socioeconomic determinants that directly influence Who is right?
people’s health, or both? Health promoters have ● Linked to this, a health promoter advocating
been criticised in the past for focusing on changing lifestyle changes can be seen as making a
the attitudes and behaviour of individuals and com- moral judgment on clients’ failure to change,
munities towards healthier lifestyles and neglecting that it is their own fault if, for example, they
the importance of the social, political and physical develop an obesity-related or smoking-related
environments on people’s lives (Jones 2003). This illness.
focus on behaviour can result in victim-blaming,
● Promoting a lifestyle change approach may
which is a significant ethical dilemma that health
produce negative and counterproductive
promoters need to address (see, for example, Rich-
feelings in the targeted individual or
ards et al 2003). It is important to note that individu-
community, such as guilt for failing to comply,
als often can change behaviour and may want to
or of rebelliousness and anger at being told
take responsibility to improve their health. Health
what to do, as some parents and children felt
promotion is an essential tool in enabling that
when Jamie Oliver attempted to change school
process, by promoting people’s self-esteem, confi-
dinners. The fall in numbers taking school
dence and empowering them to take more control
dinners was regarded as a clear indication of
over their own health. Proponents of the lifestyle
this resistance to comply (Butler 2008).
behavioural change approach also maintain that
● It cannot be assumed that individual behaviour
medical and health experts have knowledge that
is the primary cause of ill health. This is a
enables them to know what is in the best interests
limited view and there is a danger that
of their patients and the public at large, and that it
focusing on the individual’s behaviour distracts
is their responsibility to persuade people to make
attention from the significant and politically
healthier choices. Furthermore, society has vested
sensitive determinants of health such as the
that responsibility in health professionals, and
social and economic factors of racism, relative
people often seek advice and help in health matters;
deprivation, poverty, housing and
it is not necessarily a matter of persuading them
unemployment as outlined in Chapter 1 in the
against their will. Sometimes, too, individuals may
section What Affects Health?
not be in a position to take responsibility because
they may, for example, be too young, too ill or have ● Finally, it also cannot be assumed that
severe learning difficulties. See Godin (2007) and individuals have genuine freedom to choose
Taylor (2007) for a fuller debate on the advantages healthy lifestyles. Freedom of choice is often
and disadvantages of a lifestyle approach. limited by socioeconomic influences
There are several points to be taken into account (Contoyannis & Jones 2004). Economic factors
if the aim to change lifestyle is pursued: may affect the choice of food; for example,
fresh fruit and wholemeal bread are relatively
● You cannot assume that lay people believe that
more expensive than biscuits and white bread
health professionals know best. Sometimes
(Oldfield 2008, and for information on food
health experts are proved wrong and new
poverty see http://www.combatpoverty.ie).
evidence can contradict existing health
messages. For example, over the years there has Social factors are also important. Freedom of choice
been much contradictory advice on what about smoking for adolescents where both parents
constitutes a good diet (Taubes 2009), with smoke, for example, is a complex issue (Action on
some people finding the barrage of information Smoking and Health 2007). Also, how much
confusing (Health and Social Care Information freedom do people really have to change other
Centre 2008). health-demoting factors such as stressful living or
Chapter 3 Aims, values and ethical considerations 33
working conditions and unemployment? It is easy

EXERCISE 3.1 Analysing your philosophy of
to blame an individual for their own ill health, health promotion
become victim-blaming, when in reality they might
be the victims of their socioeconomic circumstances. Consider the following statements A and B:
In some disadvantaged situations and where A: The key aim of health promotion is to inform
resources of time, energy and income are limited, people about the ways in which their behaviour
health choices may become health compromises. and lifestyle can affect their health, to ensure that
What a health promoter may see as irresponsibility they understand the information, to help them
may actually be what the client sees as the most explore their values and attitudes, and (where
responsible action in the circumstances. For appropriate) to help them to change their
example, mothers confronted with the day-to-day behaviour.
pressures of parenting may smoke as a way of B: The key aim of health promotion is to raise
relieving their stress. Research by Robinson & awareness of the many socioeconomic policies at
Kirkclady (2007) indicates that while mothers who national and local level (e.g. employment, housing,
smoked in their sample acknowledged the health food, transport and health) that are not conducive
promotion messages and were aware of the health to good health, and to work actively towards a
dangers to their children of environmental tobacco change in those policies.
smoke, they resisted these messages and found 1. Taking statement A:
alternative explanations for their children’s ill-  List arguments in support of this view.
nesses which discounted their smoking.  List any points about the limitations of this
view, and any arguments against it.
Part 3 of this book is about how to promote health in a 2. Do the same with statement B.
way that is sensitive to these issues. Chapter 16 looks at 3. Do you think that the views in A and B are
what you can do to challenge and change health-related complementary or incompatible? Why?
policies. 4. Imagine these two views at either end of a
It is crucially important that everyone engaged spectrum:
in health promotion should be aware of these ethical A|. . . . .|. . . . .|. . . . .|. . . . .|. . . . .|B
concerns and have an opportunity to consider them 1 2 3 4 5
in relation to their own work, particularly if they
are engaged in interventions that aim to change Indicate the two positions on the scale of 1 to 5
individual lifestyles. Exercise 3.1 is designed to help which most closely reflect (a) what you actually do in
you to think through your views on the aims of practice and (b) what you would like to do if you were
health promotion. free to work exactly as you would choose.
(The exercise is based on an idea in the Schools Health
Education Project 5–13, published by the Health Education
Aiming for Compliance or Council and reproduced here by kind permission of the Council)
Informed Choice?
Another key question about the aims of health
promotion centres on what you aim to do with it is more likely that the health promoter will be
or for the client (whether the client is a single persuasive, will stress the risks to the client and will
individual, a community or an organisation). Is consider the session a failure if the client does not
your aim to ensure that your client complies choose to behave differently. If, on the other hand,
with your programme and changes behaviour, as is the health promoter’s aim is to enable the client to
the case with a social marketing approach? Or is it make an informed choice, the health promoter will
to enable your client to make an informed choice, ensure that the client understands the facts and the
and have the skills and confidence to carry that risks, will encourage and support the client and
choice through into action, whatever that choice accept that if the client chooses not to change their
may be? behaviour then this choice will be respected. It
For example, a health promoter is working with would not be interpreted as a failure, because the
a client whose sexual behaviour is such that there client made an informed choice.
is a serious risk of catching sexually transmitted The same issues arise with health promotion
infections, including HIV. If the aim is compliance, work on a larger scale. For example, is the aim of a
campaign to change diets and to promote the con- to comply with prescribed medication (DoH 2007b).
sumption of five pieces of fruit or vegetables a day This approach values preventive medical proce-
(Department of Health (DoH) 2007a), to persuade dures and the medical profession’s responsibility to
people to a particular point of view or to give them ensure that patients comply with recommended
the information on which to make up their own procedures.
minds? This is a difficult question. Most health pro-
moters are doing their jobs because they believe
that the action they are advocating is in the best
2. The behaviour change approach
interests of individuals, and of society as a whole.
It raises questions about how far to go in imposing The aim is to change people’s individual attitudes
your own values and ideas of what are appropriate and behaviours, so that they adopt what is deemed
lifestyle choices on other people. a healthy lifestyle (DoH 2004). Examples include
While considering this question it is also worth supporting people in stopping smoking through
noting that it raises the issue of defining success smoking cessation programmes (see National
in health promotion. In the first example (about Institute for Health and Clinical Excellence (NICE)
sexual health behaviour), if the aim is to change 2006), encouraging people to be more physically
behaviour then success is likely to be measured in active through exercise prescription or referral
terms of a drop in rates of sexually transmitted schemes (Morgan 2005), changing people’s diet
infections and unplanned pregnancies. But if the through the School Fruit and Vegetable Scheme,
aim is solely to educate in order that people can part of the five-a-day programme to increase fruit
make empowered, informed choices, success will and vegetable consumption (Blenkinsop et al
be measured in terms of changes in people’s 2007). See also NICE (2007) for evidence on the
knowledge of health risks. behavioural change approach.
Health promoters using this approach will be
convinced that a lifestyle change is in the best inter-
ests of their clients, and will see it as their respon-
Analysing Your Aims and Values: sibility to encourage as many people as possible to
Five Approaches adopt the healthy lifestyle they advocate. Health-
related social marketing fits in to this approach
There is no consensus on what is the right aim for
when the aim is to change behaviour.
health promotion or the right approach or set of
activities. Health promoters need to work out for
themselves which aim and which activities they
use, in accordance with professional codes of 3. The educational approach
conduct (if they exist), professional values and an
The aim is to give information, ensure knowledge
assessment of the clients’ needs.
and understanding of health issues, and to enable
Different models of health promotion are useful
the skills required to make well-informed decisions.
tools of analysis, which can help you to clarify
Information about health is presented, and people
your own aims and values. A framework of five
are helped to explore their values and attitudes,
approaches to health promotion is suggested with
develop appropriate skills and to make their own
the values implicit in any particular approach
decisions. Help in carrying out those decisions and
identified.
adopting new health practices may also be offered.
School personal social and health education (PSHE)
programmes, for example, emphasise helping
1. The medical approach pupils to learn the skills of healthy living, not
The aim is freedom from medically defined disease merely to acquire knowledge (OFSTED 2005; and
and disability, such as infectious diseases, cancers up-to-date guidance on the PSHE curriculum at
and heart disease. The approach involves medical http://www.pshe-association.org.uk).
intervention to prevent or ameliorate ill health, pos- Those favouring this approach will value the
sibly using a persuasive or paternalistic method: educational process, will respect individuals’ right
persuading, for example, parents to bring their chil- to choose, and will see it as their responsibility to
dren for immunisation (DoH 2006) and men over raise with clients the health issues which they think
50 screened for cholesterol and high blood pressure will be in the clients’ best interests.
4. The client-centred approach 5. The societal change approach

The aim is to work in partnership with clients to The aim is to effect changes on the physical,
help them identify what they want to know about social and economic environment, to make it
and take action on, and make their own decisions more conducive to good health. The focus is on
and choices according to their own interests and changing society, not on changing the behaviour of
values. The health promoter’s role is to act as a individuals.
facilitator, helping people to identify their concerns Those using this approach will value their demo-
and gain the knowledge and skills they require to cratic right to change society, and will be committed
make changes happen. Self-empowerment (or com- to putting health on the political agenda at all levels
munity empowerment) (Laverack 2004 and 2007) of and to the importance of shaping the health envi-
the client is seen as central. Clients are valued as ronment rather than shaping the individual lives of
equals, who have knowledge, skills and abilities to the people who live in it (Bambra et al 2005).
contribute, and who have an absolute right to Table 3.1 summarises and illustrates these five
control their own health destinies. approaches to health promotion. This framework
Table 3.1 Five approaches to health promotion – summary and example
Aim Health promotion Important values Example – smoking

activity
Medical Freedom from Promotion of medical Patient compliance Aim – freedom from lung disease,
medically defined intervention to with preventive heart disease and other
disease and prevent or ameliorate medical procedures smoking-related disorders
disability ill health Activity – encourage people to seek
early detection and treatment of
smoking-related disorders
Behaviour Individual Attitude and behaviour Healthy lifestyle as Aim – behaviour changes from
change behaviour change to encourage defined by health smoking to not smoking
conducive to adoption of ‘healthier’ promoter Activity – persuasive education to
freedom from lifestyle prevent nonsmokers from starting
disease and to persuade smokers to stop
Educational Individuals with Information about cause Individual right of free Aim – clients will have
knowledge and and effects of choice. Health understanding of the effects of
understanding health-demoting promoter’s smoking on health. They will
enabling factors. Exploration of responsibility to make a decision whether or not
well-informed values and attitudes. identify educational to smoke and act on the decision
decisions to be Development of skills content Activity – giving information to
made and acted required for healthy clients about the effects of
upon living smoking. Helping them to explore
their own values and attitudes
and come to a decision. Helping
them to learn how to stop
smoking if they want to
Client- Working with clients Working with health Clients as equals. Anti-smoking issue is considered
centred on their own terms issues, choices and Clients’ right to set only if clients identify it as a
actions that clients agenda. Self- concern. Clients identify what, if
identify. Empowering empowerment of anything, they want to know and
the client client do about it
Societal Physical and social Political/social action to Right and need to Aim – make smoking socially
change environment that change physical/social make environment unacceptable so it is easier not
enables choice of environment health enhancing to smoke than to smoke
healthier lifestyle Activity – no-smoking policy in all
public places. Cigarette sales less
accessible, especially to children,
promotion of nonsmoking as
social norm. Banning tobacco
advertising and sports’
sponsorship
has been used because it is a simple one that helps

BOX 3.1 Approaches A and B
health promoters to appreciate that there are many
approaches to health promotion, and that these dif- Approach A
ferent approaches reflect differing viewpoints and Jill is a hospital nurse running a programme of
values. The framework has been questioned and rehabilitation for patients who have had heart attacks.
challenged, and this is part of a healthy debate as She decides that she is working with an educational
the theory and practice of health promotion con- approach, aiming for her patients to make informed
tinue to develop. There are well-known models, decisions and have knowledge and skills about taking
such as the Tannahill model (Tannahill 2008) which exercise and modifying their diet and other risk factors
have helped frame approaches to health promotion. like smoking. She accepts that some patients will choose
See also Scriven (2005, p. 10) for an alternative not to do so. She thinks that sometimes she may be
framework. An important point to note is that some working in a behaviour change model, because she
of these approaches can be used together. For sincerely believes that her patients would be better off
example, a client-centred approach may also use if they changed their behaviour, and she finds that she
educational processes and a comprehensive health sometimes really wants to persuade them. In the end,
promotion strategy to deal with a public health she decides that it is their choice and their life, and that
problem. (See Box 3.1 for examples of using she will not pressure them into doing what they do not
approaches in practice). Exercise 3.2 is designed to want to do. Jill is aware, though, that some of her
enable you to think through the aims and values of colleagues (who favour the behaviour change approach)
your health promotion practice. think she should be tougher and shock patients into
complying by horror stories of what may happen to
them if they do not adjust their lifestyles.
Ethical Dilemmas Approach B
The following are some of the more common ethical Terry is a community worker, based in a deprived
dilemmas that health promoters may encounter. housing estate. Facilities for recreation, exercise and
buying good food, among other things, are poor. He
decides that he is working with a mixture of client-
Bottom Up or Top Down? centred and societal change approaches, because people
in the community have identified that they want a
There is a key issue of control and power at the better diet, and he is helping them to set up a food
heart of health promotion: who decides what health cooperative and help each other to learn new cooking
issue to target and how; who sets the agenda? Is it skills. He is also helping them to lobby their local
bottom up, set by people themselves identifying councillor for better green spaces on the estate where
issues they perceive as relevant, or is it top down, the children can play.
set by health promoters who often have the power
(supported by government policy) and the resources
to impose strategies? There is a spectrum of possi-
ble modes of interventions, from those that elimi- liberty in order to achieve overall health gain within
nate choice and remove freedom to those that just the population?
involve information giving (see Fig. 3.1). The inter- There is also a danger that, when the public is
play and interaction between individuals, commu- involved in health promotion at a local level, local
nities and the wider population is important and people can be manipulated into changing their
central to deciding on whether a top down or agenda to match that of the health promoters. Com-
bottom up approach is used. One of the difficulties munity development approaches to health promo-
in applying ethical principles in health promotion tion should be about empowering the public to
is the tension between the individual and popula- work on their own agendas of health issues, even if
tion. Decisions have to be taken about when an these are radically different from the agendas of
individual’s rights should be overridden in the those working for health in a professional capacity
interests of the greater good. Is it ever an ethical (Mittelmark 2007). But health promoters also raise
choice to initiate health promotion action that ulti- awareness of health issues; they provide informa-
mately leads to an infringement of individual tion about them and in doing so create demand for
EXERCISE 3.2 Identifying your health promotion aims and values

Select two or three specific health promotion activities With reference to Table 3.1, identify which approach
you are engaged in or have been engaged in, such as a you are using for each activity (you may find that you will
group health education programme, a media campaign, identify more than one approach).
a patient education scheme, an immunisation programme, For each activity, define the aim and the important
a one-to-one meeting with a client, a community values implicit in your work. You may find it helpful to
activity or working on a health policy. Select different look at Case studies 3.1 and 3.2
kinds of activities if you can or use Case studies 3.1 Discuss your findings with a partner or in a small
and 3.2. group.
CASE STUDY 3.1 CASE STUDY 3.2

A group of local people, led by a woman whose son An environmental health officer (EHO) wants to
died of a heroin overdose, has got together because undertake some research into the impact of air
they are concerned about drug misuse in the pollution on asthma rates in a neighbourhood that
neighbourhood. They are afraid for the safety of their straddles a main road. Town planning colleagues have
teenagers and younger children: drugs seem to be an told the EHO that they expect this road to become
established part of the teenage social scene, are even busier soon because it will become the feeder
easily available in the neighbourhood, and needles road to a new bypass leading to a massive new
and syringes are found in local alleyways. out-of-town office development. The EHO has a well
The group has decided that the best way to worked out research proposal and has the
combat drugs is to go into local schools and scare cooperation of local GPs, which will enable him to
the children off drugs with horror stories of bad see if there is any correlation between traffic flow,
‘trips’ and addiction. They have recruited a former air pollution levels and asthma rates. If he can show
drug addict who is prepared to tell his story. They a correlation, it will help to put health issues on the
have asked the school nurse to help by providing agenda of the council’s planning committee, so that
supplies of leaflets and supporting them in their the health impact of planning decisions will be taken
approach to the schools. into account in future.
The school nurse believes that the shock-horror He needs to secure a research grant to pay for the
approach the group proposes has been shown by additional pollution measurements and traffic flow
research into drug education to be ineffective. At counts, and to collect and process the data from the
best it will do no good, and at worst it could GPs. If he does not start within the next month, he
glamorise the drug scene and a make a hero out of will miss the chance to collect vital baseline
the ex-addict. She believes that the local schools’ measurements before the expected increase in traffic
approach is best: education on the facts of drug when the bypass opens.
taking and how to minimise harm from taking drugs, Despite applications to many sources, the only
coupled with building up self-esteem, social skills and offer of research money he has received has come
confidence for young people to deal with drug from a research trust which specialises in the impact
situations. The parents think this is inadequate, and of environmental pollution on respiratory disease. It is
believe that their idea for a hard-hitting approach funded primarily by the tobacco industry. The trust
will work for their children. assures the EHO that that they will not interfere with
■ Identify the ethical issues in this situation. the research in any way, and the grant will be given
■ What do you think the school nurse should do, with ‘no strings attached’. The EHO is unhappy about
and why? accepting money from the tobacco industry, but this
is now his only chance to get the research under
way.
■ Identify the ethical issues in this situation.
■ What do you think the EHO should do, and why?
Eliminate choice a position to change their lifestyle, to have the

e.g. banning smoking in public places, drink-driving laws health literacy to fully understand the health mes-
fluoridation of water supplies sages, to effectively access health services or to have
the other competencies necessary to lobby for social
Restrict choice or political changes. There is clearly a need to be
e.g. industry limits on the fat, salt and sugar content of sensitive to this (Wanless 2004).
processed food
Some ways of working with those most in need, and
often hardest to reach, are discussed in Chapter 15.
Guide choice through disincentives
e.g. tax on cigarettes and alcohol, congestion charges Efforts to change people’s physical environments
in order to improve health may have negative out-
comes. Evaluation of studies on community regen-
Guide choice through incentives
e.g. free fruit to primary school children, exercise on
eration has revealed a mixed impact, with one
prescription schemes study showing an overall deterioration in health
(Thomson et al 2006).
Guide choice through changes in policy
e.g. local planning authorities policies on transport,
school catering policies
The Health Promoter:
A Shining Example?
Enable choice Consider the cases of an overweight dietitian, a
e.g. smoking cessation clinics, cycle routes, fruit tuck nurse who smokes and an environmental health
shops in schools officer whose own kitchen is unhygienic. All
three are in a position where they need to address
Provide information these issues as part of their work and may be asked
e.g. sex education in schools, national campaigns such
for advice which they clearly do not follow
as five a day
themselves.
Few health promoters would claim that they are
Do nothing or monitor the situation perfect examples of healthy living, but we suggest
e.g surveillance of population health, community profiling that they have a responsibility to consider their own
health, and think of ways in which it could be
Fig. 3.1 Health promotion intervention ladder. (Adjusted improved and in which they could contribute to a
from Nuffield Council on Bioethics (2007, p. 42). Reproduced with permission). healthier environment. Health promoters are teach-
ing by example, and the examples discussed above
convey silent messages that it is okay to be over-
change. So where does this process differ from
weight, to smoke, or to risk health by cooking unhy-
manipulating the community into wanting what
gienically. It is probably best to be open and honest
the health promoters wanted in the first place?
in situations where health promoters’ own lifestyles
See Chapter 15. are at odds with the health promoting ways they
are advocating. Personal experience can also be
turned to good advantage: for example, if the diet
Just Widening the Inequalities?
itian has a constant struggle to control her own
As discussed in Chapter 1, there are wide differ- weight, she can use that experience to develop a
ences in the health status of different groups of greater understanding of her clients’ difficulties.
people; generally those in poorer social and eco-
nomic circumstances are the least healthy, with a
Facts, Fads or Fashions?
widening gap between the health status of rich
and poor. A concern for the public is that health advice
There is a danger that health promotion activities changes. A difficulty is that research continuously
only reach the people who have the resources and turns up new evidence. At what point do you
education to make use of health information and decide that the evidence is sufficiently convincing
take health action. Those who are trapped in poor to begin publicising a new message, or to campaign
financial circumstances are often less likely to be in to change an aspect of health policy or legislation?
If you have insufficient knowledge or experience to to take more control over their own health, need to
judge questions that may be medically or techni- seek to share their knowledge and experience with
cally complex, on what basis do you make your lay people, to learn from them, and to see them and
decision? Is it more ethical to discuss the conflicting other workers as valued partners in health promo-
views openly and just air the debate more widely? tion (Scriven 2007).
See Chapter 11 for an overview of the mass media in
health promotion. Health for Sale?
Another problem is that health issues are regu- With a scarcity of resources available for health
larly covered in the media (see The Guardian promotion and in a climate of market economy
at http://www.guardian.co.uk for an article on and income generation, some health promotion
change in exercise advice) and media attention activities are sponsored by commercial companies.
often focuses on the novel and controversial and One pitfall is the issue of perceived endorsement
often distorts the facts (Goldacre 2008). of products. For example, an NHS organisation
could be seen as promoting the use of vitamins if
it accepted sponsorship of appointment cards
Health at Any Cost? printed with the name of the sponsoring vitamin
What being healthy means to different people is manufacturer.
discussed in Chapter 1. There is also a move to involve commercial com-
panies in promoting products in a way that also
In their enthusiasm for improving health, there is a promotes health. For example, food manufacturers
danger that health promoters might lose sight that may be involved in special promotions for lower fat
health means different things to different people products. There are dangers here, the most obvious
and is shaped by their various values and experi- one being that the interests of the company may not
ences. Health may become a stereotyped image of be in harmony with those of the health promoter,
the health promoter’s own idea of perfection, who will be perceived as endorsing the product.
leading to a prescription of what people should and There is also a possibility that the independent
should not do. This is clearly contrary to the concept credibility of the health promoter is compromised.
that health promotion is about enabling people to Another pitfall is that health promotion, which
increase control over their health and improve it in should be a fundamental part of the free NHS, is
ways they see as appropriate. seen as a potential money maker. Basic services,
such as health information materials, health teach-
Health Information: An Insensitive ing, and giving advice to commercial companies on
Blunderbuss? health promotion for employees, become subject to
charges.
Health promoters should be sensitive to the social,
ethnic, economic and cultural background of the
individuals and communities with which they Individual Freedom or
work. Health information and large-scale health Community Health?
promotion programmes which portray only white Health promotion can be seen as paternalistic, inter-
Caucasians, are available only in the English lan- fering with personal liberty and freedom. Some
guage, or assume a common set of values are might hold the view that doing nothing is the most
unethical. morally acceptable option as it gives individuals the
greatest freedom. However, this does not redress
the distribution of power in society which may limit
Empower the People?
the ability of individuals (particularly vulnerable
Health promotion requires special competencies, groups) to act autonomously. Health promotion
some of which are the subject of this book. It is a addresses this by empowering individuals and
whole or part of the work of very many professions, communities to increase control over factors that
including health, education and community work. affect their health and wellbeing. However, the
Health promoters from this wide range of disci- interplay and interaction between individuals,
plinary backgrounds, if they are to empower people communities and the wider populations is
important. One of the difficulties in applying ethical Health promotion involves difficult decisions in the
principles in health promotion is the tension dividing of time and resources between individuals
between the individual and population. In what and communities, between high-risk groups and
instances should an individual’s rights be over whole populations. How do you balance general
ridden in the interests of the greater good? See campaigns on healthy eating for the whole popula-
Shaping the Future of Health Promotion and Society tion with targeted interventions, such as setting up
of Health Education and Promotion Specialists a food cooperative in a deprived area?
(SFHP/SHEPS) Cymru (2009) for a further over- The principles provide a framework for consist-
view of ethical issues, and Taylor & Harvey (2006) ent moral decision making, but health promotion
for a discussion on health promotion and the action can encapsulate complex and sometimes
freedom of the individual. conflicting choices between these principles (some
of the examples above are taken from SFHP/SHEPS
Cymru 2009). The following sets of questions (taken
Making Ethical Decisions from Seedhouse 1988) draw on the four ethical prin-
ciples and are designed for you to think about inter-
Areas of ethical concern have been raised that do vention ethics (see also Seedhouse 2009).
not present easy resolutions or answers. Beau-
champ & Childress (2001) offer four ethical princi- 1. Questions fundamental to decisions
ples which can act as a guide to ethical practice: about health
Respect for autonomy. Respecting the decision-
making capacities of autonomous persons; enabling ● Will I be creating autonomy in my clients,
individuals to make reasoned informed choices. enabling them to choose freely for themselves
Are there groups in society who might be seen as and direct their own lives?
incapable of autonomy, such as people with learn- ● Will I be respecting the autonomy of my clients,
ing disabilities, young children, prisoners, and if whether or not I approve of what they are doing?
so will this affect your health promotion approach? ● Will I be respecting persons equally, without
If an individual makes a choice that you consider discrimination?
harmful, the dilemma may be how to respect that
● Will I be serving basic needs before any other
person’s autonomy while doing good and avoiding
wants?
harm. The key question is: by what right am I
intervening and how do I justify the action I am
taking? 2. Questions about duties and principles
Beneficence. This considers the balancing of ben-
efits of an intervention against the risks and costs; ● Will I be doing good and preventing harm?
the health promoter should act in a way that ● Will I be telling the truth, based on current
benefits the client. evidence?
Non-maleficence. Avoiding the causation of harm; ● Will I be minimising harm in the long term?
the health promoter should not harm the client. The ● Will I be honouring promises and agreements?
harm should not be disproportionate to the benefits
of intervention. Victim-blaming would be consid-
ered a harm. It may not always be possible to simul-
3. Questions about consequences
taneously do good and avoid harm. For example, a ● Will I be increasing individual good?
mass media campaign showing the dangers of
● Will I be increasing the good of a particular
drink driving may have the effect of reducing the
group?
rates of drink driving but may also impact nega-
● Will I be increasing the social good?
tively on those who have been convicted of drink
driving by labelling them and/or increasing their
feelings of guilt. You will be able to think of other 4. Questions about external considerations
examples.
Justice. This involves distributing benefits, risks ● Am I putting resources to best use: what is the
and costs fairly; the notion that clients in similar most effective and efficient thing to do?
positions should be treated in a similar manner. ● What is the degree of risk involved?
● Is there a professional code of practice that has ethical decision. Not all the questions will be rele-
a bearing on this? vant, but they act as a useful checklist which will
● How certain am I of the evidence? enable careful consideration to be given to health
● Is there any disputed evidence and will I make promotion interventions.
this clear? Exercise 3.3 and Exercise 3.4 (which uses Fig. 3.1)
● Are there legal implications? If so, do I are designed to help you to think about interven-
understand them? tion ethics. Please also refer to Fig. 3.2 which pro-
vides an overview of ethical ways of working that
● What are the views and wishes of other
highlight goals and principles.
relevant people?
● Can I justify my actions in terms of the
evidence I have before me?
Towards a Code of Practice
These questions are tools to help decision making
and moral reasoning. They are not substitutes for Many professions have codes of practice, which are
personal judgements, but they help you to think broad principles and guidelines on how profession-
through your proposed actions and come to an als should and should not act. They reflect the
Ethical
health
promotion
Generic ethical principles

Do good (beneficence)
Avoid doing harm
(non-malificence)
Respect for autonomy
Justice
Ultimate goals
including
Health as a basic human right
Holistic understanding of health
Equity in health
Empowerment
Ways of working
including
Addressing the needs of disadvantaged and marginalised groups
Working participatively
Enabling individuals and communities to have control over their health, i.e. in ways which are empowering
Working in partnership with individuals, communities and sectors
Endeavoring to ensure that services have long-term positive effects
Encouraging social responsibility for health and individuals’ responsibility for their own health
Attempting to counter discrimination
Promoting trust
A commitment to sustainable development and a socio-ecological model of health
Fig. 3.2 A framework for ethical health promotion. (Taken from Shaping the Future of Health Promotion (SFHP) and Society of Health
Education and Promotion Specialists (SHEPS) Cymru 2009. Reproduced with permission).
values accepted as underpinning sound profes-

EXERCISE 3.3 Ethical decisions in health
promotion sional practice. Health promoters should ensure
they are familiar with the codes of practice of their
Look again at Case studies 3.1 and 3.2. You may find it own professional bodies See SHEPS Cymru, (2007)
helpful to use the questions in the section above on for a specific code of practice relating to health
making ethical decisions to identify the issues relevant promotion.
to each situation, and to decide what you would do.
PRACTICE POINTS
■ In choosing approaches to health promotion, take
EXERCISE 3.4 Ladder of health promotion action
account of the different aims and values they
Work in small groups of three or four. reflect.
Consider the health promotion intervention ladder in ■ Remember that ethical issues and dilemmas are
Fig. 3.1 and discuss the following: inherent in health promotion practice and you need
■ The ethical issues that might be relevant to each to think through the process of how you will make
rung of the ladder. ethical decisions.
■ Would you encounter any difficulties with any of ■ Be familiar with the code of professional practice of
the modes of interventions in practice? any profession to which you belong.
■ Are there modes of intervention that you would ■ Good practice in health promotion involves working
reject on ethical grounds? to the specific values and principles of practice.
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45
Chapter 4
Who promotes health?
Summary
Chapter Contents
In this chapter the major agents and agencies of
Agents and agencies of health promotion 46 health promotion are identified, and their roles
discussed. Included are international and national
International agencies 46
organisations, the government, the NHS, local
National agencies 48 authorities and voluntary organisations. There is an
exercise on identifying key local health promoters and
Other local organisations and groups 56
the chapter ends with suggestions for practice and an
Improving your health promotion role 57 exercise about how you can improve your own health
promotion role.
This chapter provides an overview of the people

and organisations that support and enable better
health. To some extent many lay people are health
promoters, because they discuss health matters and
offer support, advice and guidance to others. This
can happen informally. The unofficial networks of
family, friends and neighbours are of great signifi-
cance in shaping people’s health beliefs and behav-
iour, in providing healthy living conditions and
creating social capital. Health promotion may also
occur incidentally. The availability of a wide variety
of cheap fruit and vegetables in the summer, for
example, means that it is easier for people to choose
a healthy diet, so the greengrocer is inadvertently
promoting health. These informal and unplanned
sources of health promotion are very significant.
The aim here, however, is to identify the agents and
agencies through which planned, deliberate pro-
grammes and policies are delivered.
England, Wales, Scotland and Northern Ireland
have public health systems which differ slightly but
all countries support the following health policy

International Agencies
themes:
● Modernisation: using up-to-date streamlined The European Community
methods of management and communication in
health (Department of Health (DoH)/NHS In 2007 the EU developed a new public health strat-
Modernisation Board 2003 and http://www. egy, Together for Health: a strategic approach for the
dh.gov.uk). EU 2008–2013 (Commission of the European Com-
munities 2007). The strategy brings together and
● Equity and inequalities: equal opportunities
extends the public health programme and the pro-
for everyone and reducing health inequalities
gramme in support of EU consumer policy. As
between different social groups (DoH
public health and consumer protection policies
2007).
share many objectives, such as promoting health
● Social and economic regeneration: addressing
protection, safety, information and education, the
poverty, unemployment, poor living conditions commission aimed, in combining the two pro-
and social exclusion (a sense of not being a grammes, to exploit synergies and to generate
part of a community, of not belonging) greater health policy coherence.
(http://www.publicservice.co.uk).
● Democratic renewal: ensuring that the process of The WHO’s role in promoting health is also discussed in
democracy is applied through all levels of public Chapter 1.
service (http://www.communities.gov.uk).
● Public involvement: getting people involved The Who
with decisions and actions that affect them,
The WHO (http://www.who.int) has a role in
such as consulting people about proposed
guiding both European and global health policy. It
changes to local health services (http://www.
has issued many statements in the form of declara-
publicinvolvement.org.uk).
tions and charters addressing important and broad
areas of health promotion and public health-related
policy. It coordinates European networks such
Agents and Agencies of as Health Promoting Schools and Hospitals, and
Health Promotion Healthy Cities. These initiatives are discussed more
fully in Chapter 16.
Fig. 4.1 identifies a wide range of the most impor-
tant agents and agencies of health promotion. Most
Other International Agencies
have a variety of health promotion roles.
See Chapter 9, section on working in partnership with The International Union for Health
other organisations. Promotion and Education (IUHPE)
An increasing number of agencies work together in The IUHPE (http://www.iuhpe.org) is half a
collaborative partnerships, in an effort to make century old, and is the only global organisation
their work more effective. Partnership working has entirely devoted to advancing health promotion
been a dominant theme in national and interna- and health education. It is a leading global network
tional health promotion and public health direc- working to promote health worldwide and contrib-
tives since the Ottawa Charter (World Health ute to the achievement of equity in health between
Organization (WHO) 1986). In the UK it has been and within countries. It has an established track
part of all the national strategies for health (see, for record in advancing the knowledge base and
example, DoH 1992, 1999, 2004) and these have improving the quality and effectiveness of health
been accompanied by guidance on how agencies promotion and health education practice, with
could work together for better health (see for members ranging from government bodies, to
example, the Welsh Partnership Forum constitution universities and institutes, to nongovernmental
at http://www.cymru.gov.uk). Government strate- organisations (NGOs) and individuals across all
gies and guidelines continue to focus on the impor- continents.
tance of partnerships for health between agencies The IUHPE decentralises its activity through
and across government departments. regional offices and works in close cooperation with
Chapter 4 Who promotes health? 47
National government International

e.g. Department organisations
of Health e.g. WHO
Private preventive National voluntary

medical services organisations and
e.g. private health checks pressure groups
e.g. RoSPA
Local government National and local media

e.g. TV, radio, Professional
e.g. teachers,environmental
newspapers, Internet organisations and
health officers, social
trade unions
workers
Police, probation, Health and Safety

fire-fighters Executive
Local community and National Health Service

voluntary groups e.g. national health
e.g. youth groups, development agencies,
self-help groups local health workers
Local branches of Commercial and

national organisations The informal network industrial organisations;
e.g. Citizen's Advice Bureaux e.g. family, friends, manufacturers and retailers
neighbours
Institutions of Workplace employers

higher learning e.g. occupational health
e.g. colleges and universities services, human resources
managers
Complementary health
Churches and religious
practitioners
organisations
e.g. osteopaths
Fig. 4.1 Agents and agencies of health promotion.

the major intergovernmental and NGOs such as

National Agencies
WHO, UNESCO, UNICEF, to influence and facili-
tate the development of health promotion strategies The Government
and projects.
The IUHPE has four goals: Government departments in the UK (and their
1. Advocate for health: to advocate for actions devolved counterparts in Wales, Scotland and
that promote the health of populations Northern Ireland), such as the Department of
throughout the world. Health, the Department of Work and Pensions, the
Department for Education and Skills (DfES), the
2. Build knowledge of effective health promotion
Department of the Environment, Food and Rural
and health education: to develop the
Affairs and the Department of Transport, Local
knowledge base for health promotion and
Government and the Regions, have an interest in
health education.
and responsibility for the promotion of health and
3. Improve effectiveness of policy and practice: to therefore have to take account of the impact of
improve and advance the quality and legislation and economic and fiscal policies on
effectiveness of health promotion and health health.
education practice and knowledge. The national public health strategies for health in
4. Build capacity for health promotion and health England, Wales, Scotland and Northern Ireland
education: to contribute to the development of demonstrate a commitment towards the pursuit
capacity in countries to undertake health of improved health and a reduction in health ine-
promotion and health education activities qualities, rather than focusing just on treatment
(http://www.iuhpe.org). services and health care. To this end, key units have
been established, for example, neighbourhood
renewal (http://www.neighbourhood.gov.uk) and
the social exclusion taskforce (http://www.cabinet
European Public Health Alliance (EPHA)
office.gov.uk) to produce national directives to be
The EPHA (http://www.epha.org) is a network of implemented locally by partnerships of health serv-
NGOs (NGOs are organisations that are independ- ices, local authorities, and voluntary and commu-
ent of government control) and other agencies nity organisations.
actively involved in protecting and promoting
See Chapters 1 and 7 for more on national strategies for
public health. EPHA’s mission is to promote and
health.
protect the health of all people living in Europe and
to advocate for greater participation of citizens in The UK government has also taken a lead in
health-related policy making at the European level. tackling health issues such as drug misuse (DoH
2008a) and teenage pregnancy (Department for
Children, Schools and Families (DCSF) 2007, DoH/
DfES 2008). In relation to drug misuse, for example,
World Federation of Public Health its aims are to increase the safety of communities
Associations (WFPHA) from drug-related harm, to reduce the acceptability
The WFPHA (http://www.wfpha.org) is an inter- and availability of drugs to young people and to
national, nongovernmental, multiprofessional and reduce the health risks and other damage related to
civil society organisation bringing together public drug misuse. Multiagency drug action teams
health professionals interested and active in safe- produce local plans, coordinate work and bring
guarding and promoting the public’s health through together a wide range of people and agencies to
professional exchange, collaboration and action. It work at a local level.
is the only worldwide professional society repre-
senting and serving the broad area of public health,
Other National and Local Agencies
as distinct from single disciplines or occupations
(such as the IUHPE). The Federation’s members are
national and regional public health associations, as
Non-governmental organisations
well as regional associations of schools of public There are a number of NGOs concerned specifically
health. with public health in the UK, such as The Royal
Society for Public Health, the UK Public Health ences, ideas and information. It is a professional
Association and The Institute of Health Education association with a recognised role in the field of
and Health Promotion. prevention and management of illness and promo-
tion of health. Its activities have been mainly con-
The Royal Society for Public Health (RSPH) cerned with health education, and following the
The RSPH (http://www.rsph.org.uk) is an inde- Declaration of Alma Ata (WHO 1978) they also
pendent organisation dedicated to the promotion include health promotion. The IHPE has been in the
and protection of population health and wellbeing. forefront of health promotion developments with
It advises on policy development, provides educa- special contributions to the advancement of a set-
tion and training services, encourages scientific tings approach.
research, disseminates information and certifies
products, training centres and processes. The RSPH
Voluntary organisations and pressure groups
is the largest multidisciplinary public health organi-
sation in the UK and is an independent charity There are many voluntary organisations concerned
formed in 2008 by the merger of the Royal Society with health promotion, some of which have regional
of Health (RSH) and the Royal Institute of Public and/or local branches. Examples of these are The
Health (RIPH). Shaping the Future of Health Promo- Advisory Council on Alcohol and Drug Education
tion is hosted and led by the Royal Society for Public (TACADE) (http://www.tacade.com) and the
Health (in collaboration with the Faculty of Public National Association for Mental Health (MIND)
Health, UK Public Health Register and Institute (http://www.mind.org.uk). Most of these organi-
of Health Promotion and Education). This impor- sations produce educational material, and some run
tant project derived from the main recommenda- training courses for professionals and/or the public.
tions of the 2005 report Shaping the Future of Public Some organisations act mainly as pressure groups,
Health: Promoting Health in the NHS (DoH/Welsh such as Friends of the Earth (http://www.foe.
Assembly Government 2005). Through this co.uk).
project the RSPH advocates for the importance of
specialised health promotion within public health Professional associations
and supports the specialised health promotion
workforce. Professional associations, such as the British
Medical Association (BMA) (http://www.bma.org.
The UK Public Health Association (UKPHA) uk), the Royal College of Nursing (RCN) (http://
The UKPHA (http://www.ukpha.org.uk) is an www.rcn.org.uk), the Chartered Institute for Envi-
independent voluntary organisation which aims to ronmental Health (CIEH) (http://www.cieh.org)
be a unifying and powerful voice for the public’s and the Faculty of Public Health (FPH) (http://
health and wellbeing in the UK, focusing on the www.fphm.org.uk) have been highly influential
development of healthy public policy at all levels of in policy and legislative changes and in the
government and across all sectors. Their mission practice and training of their members in health
includes three aims: promotion.
1. To combat health inequalities and work for a
fairer, more equitable and healthier society. Trade unions
2. To promote sustainable development, ensuring Trade unions are active in promoting health and
healthy environments for future generations. safety at work, both through negotiating workplace
3. To challenge anti-health forces, collaborating conditions and through their health and safety rep-
with business to promote health-sustaining resentatives (Barbeau et al 2005). In the UK, The
production, consumption, employment and Health and Safety Executive (HSE) (http://www.
socially responsible products and services. hse.gov.uk) also oversees the implementation of
health and safety at work legislation.
The Institute of Health Promotion and Education (IHPE)
The IHPE (http://www.ihpe.org.uk) was estab-
Commercial and industrial organisations
lished to bring together professionals on the basis
of their common interest in health education and These have a role in safeguarding public health.
health promotion with a view to sharing experi- Examples include companies providing water and
refuse removal companies. In recent years in the fundamental reorganisation happened in the 1990s,
UK, some facilities with a public health protection starting with the National Health Service and Com-
function have been privatised, which has raised munity Care Act reforms (DoH 1990). During the
public health dilemmas. For example, should water 1990s, a key feature of the NHS was the internal
companies have the right to cut off supplies to con- market and the division into purchasers and provid-
sumers who do not pay their bills, when a possible ers. Local health authorities were the purchasers,
consequence of this is the occurrence and spread of who decided what health care was required and
infectious diseases such as dysentery? purchased it, setting and monitoring contracts with
provider local hospitals and community services.
Manufacturers and retailers These providers became NHS trusts, in competition
with one another to win contracts from the purchas-
Manufacturers have increasingly taken the health ers. The election of a new government in 1997
and safety aspects of their products into account. brought an approach which emphasised integrated
These include manufacturers of children’s toys, care, and working in a spirit of cooperation. The
food manufacturers and producers of green eco New NHS: Modern, Dependable (DoH 1997) set out
household products. Large supermarket chains the plan for the health service, with partnership,
have made a wide range of healthy options avail- quality and performance at the heart of the NHS, a
able to the public, such as fat-reduced and low- focus on improving health and wellbeing, and
sugar foods. These trends are often as a result of tackling the root causes of ill health and inequali-
increased consumer demands, reflecting height- ties. A separate White Paper was published for
ened awareness of health issues (House of Scotland (DoH/Scottish Office 1997). In a shift
Commons 2002). towards a primary care-led NHS, primary care
groups (PCGs) were set up in the late 1990s. These
The mass media were basically groups of GP practices that worked
closely with local authorities, especially social serv-
Health promotion is undertaken by national and ices, to assess local health needs and develop local
local mass media organisations, including televi- health services. The NHS Plan (DoH 2000) set out a
sion, radio, newspapers and magazines (Hubley & further programme for reform, investment and
Copeman 2008), and through the Internet many expansion of the NHS, including a central role for
people have easy access to a huge range of health the wider public health function, including health
information (Korp 2006). promotion.
See Chapter 11 for more about mass media in health
promotion. See below for information on primary care trusts.
Shifting the Balance of Power Within the NHS –

Churches and religious organisations Securing Delivery (DoH 2001) set out further change
Churches and religious organisations play an with a power shift to frontline staff. Primary care
important part in developing values, attitudes and groups were given additional responsibilities to run
beliefs that affect health. Kramish Campbell et al services; they developed into primary care trusts
(2007) show how church-based health promotion (PCTs) with a responsibility to work closely with
can influence members’ lifestyle at multiple levels social services.
of change and produce significant impacts on a Larger strategic health authorities replaced the
variety of behaviours. existing smaller health authorities in England in
2002. Strategic health authorities support the PCTs
and NHS trusts in delivering The NHS Plan, to build
The National Health Service (NHS)
capacity and support performance improvement,
ensuring that all NHS organisations work together
The structure of the NHS to meet government targets. (See http://www.nhs.
The NHS, established in 1948, has been reorganised uk for an interactive timeline which details mile-
on a regular basis, usually as a new government is stones in the history of the NHS from its very begin-
voted into power. The most significant and ning in 1948 to the present day.)
Secretary of State
for Health
Department of Health
and NHS Executive
Strategic health
authorities
Primary care trusts NHS trusts

(seconday care)
Primary health care Secondary health care
Community GPs Dentists Pharmacists Opticians Hospitals Mental Learning Ambulances

health health disability
services services services
Fig. 4.2 The structure of the NHS in England since April 2002. (Figure adjusted from Office of Health Economics website: http://www.
ohe.org/page/knowledge/schools/hc_in_uk/nhs_structure.cfm. Reproduced with permission).
In 2002, the Department of Health was refocused. hospitals but also ambulances and specialised
Figs 4.2 and 4.3 show the overall structure of the health services for the mentally ill and the learning
NHS in England. At the top in Fig. 4.2 is the Secre- disabled, as shown in Fig. 4.2.
tary of State for Health, the government minister in Services are provided by NHS organisations
charge of the Department of Health, responsible for called trusts. NHS trusts supply secondary care.
the NHS in England and answerable to Parliament. PCTs provide primary care services and are respon-
The Department of Health and the NHS Executive sible for buying almost all of the health care, both
are responsible for the strategic planning of the primary and secondary, required by the local popu-
health service as a whole. Under the Department of lations they serve (see more on PCTs and NHS
Health are strategic health authorities which plan trusts under Agents of Health Promotion, below).
health care for the population of the region they The structures in Scotland, Wales and Northern
cover. Ireland differ. In the interests of keeping the text
Health services are divided between primary in this book short, the terms used are applicable
and secondary. Primary care services include to England but readers in all countries will need
general medical practitioners (GPs), dentists, phar- to familiarise themselves with the structure in
macists, opticians, district nursing and numerous the country where they work by undertaking
other services. Secondary care includes not only Exercise 4.1.
Primary care
GP practic
Department of health
(DH) “funding, directing
tists
NH ntres
and supporting the
Den
ce
Sw
e
s NHS”
ian
s
alk
c
pti
-in
O
NHS Information
dire
ct
ts
macis
Patients and public Phar
Primary care trusts
Emergency (PCTs) “assessing
Quality
Choice Care
and local needs and
urgent care commissioning care”
Care
trust
s
la nce Safety
bu
Am sts Me ts Strategic health
tru
trus
nta
authorities (SHAs)
sts
l he
“managing, monitoring
NHS tru
alth
and improving local

services”
Secondary care
Fig. 4.3 The structure of the NHS. (Source http://www.nhs.uk/NHSEngland/aboutnhs/Pages/NHSstructure.aspx. See http://www.nhs.uk for further
details on the diagram and the structure, core principles and history of the NHS. Reproduced with the permission of NHS Choices).
EXERCISE 4.1 What’s on your patch? Finding out about your local NHS and agents and agencies of
health promotion
Exercise 4.1 is designed to help you to find out how your It could be the area served by a GP practice, the
local NHS is organised and to identify the health catchment area of a hospital, the population of a
promotion agents and agencies which are important for primary care trust/care trust or the geographical
your work. There is much to gain by having good local patch that is your responsibility as an
knowledge of health promoters you can refer clients to or environmental health officer or community
work with in partnerships. worker.
1. Find out about the structure of the NHS in the area  Identify as many health promotion agents and
where you work: agencies on your patch as you can, using
 What is the name and function of the local Fig. 4.1 and the information about agents and
organisation with responsibility for public health? agencies in health promotion in this chapter as
(This will be your local primary care trust/care checklists.
trust or its equivalent in Scotland, Wales or It is likely that you will know some very well and others
Northern Ireland. Try http://www.nhs.uk for not at all. Identify those you would find it helpful to know
information.) more about and plan to find out about them. If there are
 What regional and/or national organisations are some you know nothing about, such as the voluntary and
responsible for public health where you work? community groups on your patch, identify people who are
2. Find out about the agencies and people on your likely to know about them (such as health promotion
patch: practitioners/specialists) and contact them to find out
 Think of the geographical patch where you work, more.
and identify its boundaries as clearly as you can.
National Institute for Health and Clinical standards. Since 2008, PCTs can choose to adopt the
Excellence (NICE) NHS prefix before their place name. The Next Stage
Review report (DoH 2008b) signalled that PCTs have
NICE is currently the national agency responsible the freedom to re-name to NHS Local. This will
for providing national guidance on promoting allow PCTs to position themselves as the local
good health and preventing and treating ill health leader of the NHS and frontline commissioners of
(http://www.nice.org.uk). NICE took over the patient care. It is integral to the objectives of world
functions of its predecessor, the Health Develop- class commissioning (http://www.dh.gov.uk) and,
ment Agency (HDA) on 1 April 2005. The HDA was in particular, that PCTs have responsibility for all
a special health authority established in 2000 to primary care services (pharmacy, dental, medical
develop the evidence base to improve health and and optical).
reduce health inequalities. If you would like to Improving the health of the local community
know more about the HDA, see the White Paper involves PCTs in programmes of community devel-
Saving Lives: our Healthier Nation (DoH 1999). opment, health promotion and education. One
means of doing this is through local strategic part-
Health Scotland nerships (LSPs) involving all the local NHS organi-
sations, local authorities, voluntary and community
The work of Health Scotland covers every aspect of groups and local businesses. LSPs ensure that prior-
health improvement, from gathering evidence, to ity is given to shared plans and integrated multi
planning, delivery and evaluation, and spans the agency programmes (http://www.neighbourhood.
range of health topics, settings and life stages gov.uk). An example of this is teenage pregnancies
(http://www.healthscotland.com). (DoH/DfES 2008) with those LSPs in receipt of
neighbourhood renewal funding (NRF) asked to
Public Health Agency for Northern Ireland work towards reducing teenage conception rates.
All NRF and their LSPs operate within the context
The Agency began work in 2009 following a review, of local area agreements (LAAs). LAAs set out the
which saw a range of functions in the health and priorities for a local area agreed between central
social care system brought together to focus on government and a local area (the local authority
improving the health and wellbeing of everyone in and LSP) and other key partners at the local
Northern Ireland. The Agency works with a wide level.
range of partners from the health, voluntary and
community sectors, as well as local government For more detail, see Chapter 7, section on local health
(http://www.publichealth.hscni.net). strategies and initiatives.
Health promotion division: the National

Assembly for Wales NHS and foundation trusts
The National Assembly for Wales approach to NHS trusts provide patient-centred hospital serv-
health improvement is to promote positive health ices based on local agreements and national stand-
throughout life, from healthy children to healthy ards; some trusts provide specialised services such
ageing. Lifestyle changes that will improve health as mental health services or ambulance services.
are encouraged, and by supporting communities to NHS trusts are expected to take account of patients’
change a range of factors affecting health in the views as they plan their services, and to ensure that
environment, the workplace and local government. local people are involved in decisions about service
The focus is on preventing ill health and on planning. NHS trusts have a part to play in health
addressing problems at an early stage (http:// promotion, particularly health education and pre-
wales.gov.uk). ventive health work with patients, their carers and
families.
Foundation trusts are a new type of NHS hospi-
Primary care trusts
tal introduced in 2004 and run by local managers,
PCTs have control of local healthcare while strategic staff and members of the public, which are tailored
health authorities monitor performance and to the needs of the local population. Foundation
trusts have been given much more financial and 365 days a year and are situated in convenient loca-
operational freedom than other NHS trusts and tions that give patients access to services beyond
have come to represent the government’s com regular office hours (http://www.nhs.uk).
mitment to decentralising the control of public
services. These trusts remain within the NHS and
its performance inspection system (http://www. Public health observatories
nhs.uk).
The Association of Public Health Observatories
(APHO) represents a network of public health
Patient advice and liaison services observatories (PHOs) working across the five
nations of England, Scotland, Wales, Northern
Patient advice and liaison services (PALS) are Ireland and the Republic of Ireland. They produce
designed to bring citizens more closely into deci- Health Profiles which provide information, data
sion making processes. They provide: and intelligence on people’s health and health care.
● Confidential advice and support to families and Health Profiles provide a snapshot of health for
their carers, information on the NHS and each local council using key health indicators,
health-related matters. which enables comparison locally, regionally
● Confidential assistance in resolving problems and over time (http://www.apho.org.uk).
and concerns quickly.
● Explanations of complaints procedures and how
to get in touch with someone who can help. Agents of Health Promotion
● Information on how people can get more
involved in their own healthcare.
Primary healthcare teams
Each NHS hospital has its own PALS. In addition, Primary healthcare teams are usually the first point
each primary care trust, ambulance trust, acute of contact that the general public has with the NHS.
trust, care trust and mental health trust has its own The exact membership of each primary healthcare
PALS (see DoH 2006 and http://www.nhs.uk). team varies but it usually includes the following:
Health promotion specialists

NHS Direct Health promotion specialists (sometimes known by
NHS Direct is a national telephone helpline in other professional titles such as public health prac-
England which is staffed by specially trained nurses titioners) are mostly located within the public
24 hours a day, 365 days a year. They have the health directorate in PCTs and are responsible for
knowledge and experience to give help and re the provision of expert advice, leadership, partner-
assurance but also offer commissioned services to ship development, training, programme develop-
other parts of the NHS to help them meet their ment (including strategy and policy) and resources
patients’ needs. to support local health promotion initiatives. They
These services include out-of-hours support for liaise with other health promotion agents and agen-
GPs and dental services, telephone support for cies, both within and outside the NHS, to ensure
patients with long-term conditions and pre- and that activities, wherever initiated, are coordinated
postoperative support for patients (http://www. and supported.
nhsdirect.nhs.uk).
General practitioners
GPs provide a comprehensive range of diagnosis
NHS walk-in centres and treatment medical services for patients regis-
NHS walk-in centres (WiCs) offer access to a range tered with their practice, and for those outside the
of NHS services. WiCs are managed by PCTs and practice in an emergency. They refer patients to
deal with minor illnesses and injuries. They are pre- other healthcare workers as necessary, for example
dominantly nurse-led first-contact services availa- to counsellors, practice nurses, health visitors,
ble to everyone without making an appointment or physiotherapists or consultants specialising in a
requiring patients to register. Most centres are open particular disease area. Encouraging healthier
living is an important part of a GP’s work. Health 2008c). The initiative was first targeted at the most
promotion via GPs can come in the form of guid- disadvantaged areas to make it easier for individu-
ance on lifestyle choices or it can be implemented als in these communities to make healthier choices
through immunisation or screening programmes (http://www.dh.gov.uk).
(Kula 2007). The Royal College of General Practi-
tioners’ GP curriculum statements say that GPs
have ‘a crucial role to play in promoting health’ Health Promotion Agents and
(http://www.rcgp-curriculum.org.uk). Agencies Outside the NHS
GP practice managers Complementary and alternative medicine

These are key people in enabling the smooth (CAM) practitioners
running of practices and for ensuring that patients Those practising CAM include homoeopaths,
are efficiently, confidentially and caringly received. chiropractors, osteopaths, acupuncturists, reflex
They have an important role in health promotion ologists, practitioners of herbal medicine, yoga,
because they can control access to health informa- massage and shiatsu, among others. These practi-
tion for patients. tioners can play a part in promoting health and
relieving health problems, often using a more holis-
Community nurses tic approach than conventional medicine. Therapies
PCTs depend on the contribution of a range of com- may be available on the NHS, either by a member
munity nurses to achieve their objectives; their of the primary care team or through referral to a
work in health promotion and in assessing health complementary practitioner. There is potential for
needs of the local population is particularly impor- collaboration and closer integration between health
tant (Weeks et al 2005). There is a range of nursing promotion and complementary therapies, with Hill
roles and professions within community nursing, (2003) arguing that health promoters cannot afford
including: to ignore developments in CAM.
● district nurses
● health visitors
● school nurses
Local authorities
● community mental health nurses Local authorities have responsibilities that impact
● community midwives on the social, economic and environmental factors
● practice nurses that affect health, such as poverty, low wages,
unemployment, poor education, substandard
● others, such as diabetes specialist nurses.
housing, crime and disorder, and pollution.
Working with others, they will be able to develop
Other health professions strategies for tackling many of the fundamental
Many other health professionals, such as hospital causes of ill health; for example, either by targeting
nurses (Whitehead 2005a,b), dentists, hospital and housing maintenance or coordinating different
retail pharmacists (Armstrong et al 2005) and the types of information services. In doing so, they are
full range of professions allied to medicine (Scriven fundamental to health development in the commu-
2005) have a part to play in health promotion, espe- nities they serve (http://www.direct.gov.uk).
cially in patient education.
See also Chapter 9 section on working in partnership
with other organisations.
Health trainers
Health trainers are a new workforce recruited from A host of initiatives has been developed over the
the community and working in the NHS, local last decade to promote and improve economic,
organisations including local authorities, busi- social and environmental wellbeing, through regen-
nesses, the voluntary and community sector. Health eration and partnership working. These have been
trainers motivate and help people to set goals by encouraged by the Beacon Scheme, a prestigious
developing personal health plans, give practical award scheme that recognises excellence in local
support to carry out those plans and identify with government (http://www.beacons.idea.gov.uk).
the individuals their barriers to change (DoH See the example in Case study 4.1.
CASE STUDY 4.1 CALDERDALE LOCAL HEALTH supporting the role and function of environmental
STRATEGY health as well as delivering and developing a
number of health promotion projects. For a specific
Through its strong and committed partnerships, example of an EHPO, see East Herts LA (http://
Calderdale has developed effective structures for the www.eastherts.gov.uk).
development of strategies and delivery of the health
agenda. The partnership between the council and the
Calderdale and Kirklees Health Authority, Calderdale The local education authority
NHS Trust, Calderdale Primary Care Group and the
Local education authorities (LEAs) have responsi-
voluntary sector in the borough has embraced the
bility for personal, social and health education
issues of broader regeneration and quality of life
(PSHE) in schools. They may employ advisors
agenda in both the health improvement programme
to provide advice, support and training for teachers
and the council’s community plan.
in PSHE. PSHE includes everything schools do
The council and its partners have been able to
to promote pupils’ good health and wellbeing.
recognise complex causes of ill health, making clear
It is backed by the National Healthy Schools
links with national policies, and have set out a vision
Programme (http://www.teachernet.gov.uk) and
to promote social equality and economic and
is linked to Citizenship (http://www.standards.
environmental wellbeing. The key outcome has been
dfes.gov.uk).
the effective joint planning and strategy development
between chief executives and leaders from the
council and the health service through the
multiagency health policy group.
Social services
(http://www.beacons.idea.gov.uk) Social services staff, including social workers and
staff of care homes, are concerned with improving
or maintaining the health of clients. With the policy
of providing care in the community rather than
hospital, the role of social services departments
in promoting the health of vulnerable groups such
For more detail see Chapter 7, section on local health as older people, people with mental health prob-
strategies and initiatives. lems and people with learning difficulties has
increased greatly (see http://www.direct.gov.uk
for the range of social services available).
Environmental health officers/practitioners Many other local authority staff have a health
Environmental health officers (EHOs) work in promotion role, such as recreation and leisure offic-
environmental protection, food safety and nutri- ers, housing officers, regeneration, youth and com-
tion, health and safety, housing and public health munity workers, trading standards and community
(see http://www.cieh.org for specific details on safety officers.
EHOs roles and functions).
The organisation of environmental health
services is mainly the function of local authority
environmental health departments, but may be
Other Local Organisations
combined with other departments such as housing,
and Groups
community development and leisure. National and
There are numerous individuals and groups at local
local legislation gives these departments power to
level who help to promote particular aspects of
take advisory and legal action on behalf of people
health. Some notable ones are described here.
who visit, live or work in an area. The scope for
health promotion is wide. Many departments
appoint specialist officers to work on specific health
Higher Education Institutes
issues, such as home safety. Some environmental
health services have full-time environmental Universities are responsible for the basic training
health promotion officers (EHPOs) who work in of health promotion professionals. They are also
involved in post-basic and continuing education building capacity and capability is recognised
for health promoters, including running postgra (WHO 2005, Scriven & Spellar 2007), but one of the
duate diplomas and masters level courses (König difficulties is how to fit more into the already
2008). crowded curriculum of basic professional training
courses.
Voluntary and Community Groups Postgraduate diplomas and masters degrees in
health education, health promotion and public
A huge range of voluntary and community groups health are available, often in a range of learning
exists that undertake education and support modes. More recently, training in health promotion
activities on health matters. Patients’ associations, is being adapted to meet the public health occupa-
self-help groups, environmental action groups and tional standards of competence and to move
youth groups are just a few examples. The impor- towards a professional registration system for those
tance of the voluntary sector in health improvement who want to work in a specialist capacity in health
is demonstrated by the government’s commitment promotion.
to funding these organisations (Jerrom 2007).
See Chapter 2 for details of the national occupational
Employers standards relevant to health promotion.
Employers can be active in developing and imple- All these developments help to ensure the quality
menting health promoting policies in the work- of health promotion work. Resource constraints
place. Human resource officers and occupational caused by staff shortages or work overload may
health staff, in particular, are vital to implementing hinder the professions from achieving their poten-
the government’s The Health, Work and Well-being tial in health promotion. On a positive note,
Strategy (Department for Work and Pensions et al some strategies, such as partnership working, will
2005). improve the capacity in health promotion. The con-
tinued building of multiprofessional understand-
Police and Probation Officers ing, partnerships and capabilities and pulling
together of the different professional groups under
The police protect the public from crime and vio- the banner of health promotion is vital to future
lence, take action to prevent misuse of drugs and success (Scriven 2005).
alcohol and help to ensure road safety. Prison offic- Exercise 4.2 is designed to enable you identify
ers and probation officers are involved in the health factors that help and hinder you in carrying out
and wellbeing of prisoners and their families, and health promotion work, and consider what you
may be involved in initiatives such as health pro- might do to improve the situation.
moting prisons (DoH 2002), education about HIV/
AIDS, and educational programmes on sensible
drinking for drink/drive offenders. PRACTICE POINTS
■ It is important to appreciate the whole range of
Fire Fighters agents and agencies with a health promotion role:
The fire service has a key role to play in preventing informal and formal, local, national and
injuries at home and on the roads; they may run international.
innovative projects such as schemes inviting people ■ Think about how you can best work with other
to bring in electric blankets for a safety check people and agencies.
(http://www.fireservice.co.uk). ■ Ensure that you are clear about your role and
responsibilities in health promotion.
■ Consider how you could improve your health
Improving Your Health promotion role, through education and training or
Promotion Role through identifying what helps and hinders your
health promotion work and how the situation could
A number of factors affect the development of the be improved.
health promotion role of professionals. The need for
EXERCISE 4.2 What helps and hinders your health promotion work?
This exercise is designed to help you identify helping and ■ Make a list of forces that hinder you in your health
hindering forces in your own situation. promotion work.
In a stable system, the forces for producing changes are ■ Identify ways of increasing the helpful forces.
balanced by forces opposed to change. It is essential to ■ Identify ways of decreasing the hindering forces.
pinpoint all the possible helping and hindering forces, so → health ←
that you can take steps to increase the power of helping helping forces → promotion ← hindering forces
forces and decrease the power of hindering forces. The → work ←
disruption of the balance results in progress towards
→
change.
Direction you want to go
For your own situation:
■ Make a list of forces that help you in your health
promotion work.
References
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61
PART 2
Planning and managing

for effective practice
Part Contents
5. Planning and evaluating health promotion 63
6. Identifying health promotion needs and priorities 77
7. Evidence and research in health promotion 91
8. Skills of personal effectiveness 107
9. Working effectively with other people 121
Part Summary
Part 2 aims to provide guidance on how you can: how you will know whether you are succeeding. The
● Plan and evaluate your health promotion work meaning of terms such as aims, objectives and targets
using a basic framework. are discussed, and there is guidance on how to specify
● Identify the views and needs of the clients/users/ them.
receivers of health promotion, and set priorities for Chapter 6 explains how to identify need, and
your work. describes the sources of information you require to
establish the needs of a community, a group or an
● Link your work to the efforts of colleagues and to
individual. Guidelines are provided on how to gather
local and national strategies.
and apply information in order to assess needs and set
● Use an evidence-based approach, through using
priorities.
published research, doing your own research when
Chapter 7 provides an overview of the knowledge
necessary and auditing your work, thus ensuring
and skills required to plan health promotion activities
that your efforts are effective and provide value
effectively, including how to find and use published
for money.
research. Guidance is included on how you can contrib-
● Organise yourself and manage your work in order ute to national and local public health strategic plans
to be effective and efficient. and complement what other people are doing. Evi-
● Develop skills to work more effectively with dence-based health promotion is discussed and advice
colleagues and people from other organisations. offered on how you can carry out small-scale research,
Chapter 5 sets out a seven-stage planning and evalu- audit your activities and ensure value for money. The
ation cycle, which will help you to clarify what you chapter ends with a description of the key steps
are trying to achieve, what you are going to do and required to undertake a health impact assessment.
Chapter 8 focuses on how you can develop the skills Chapter 9 is about how to work with other
to manage yourself and your work effectively, including people, including communicating with colleagues,
managing information, writing reports, using time coordination and teamwork, participating in meetings
effectively, planning project work, managing change and working in health partnerships with other
and working for quality. organisations.
63
Chapter 5
Planning and evaluating health promotion
Summary
Chapter Contents
This chapter presents an outline of a planning and
The planning process 63 evaluation cycle for use in the everyday work of health
promoters. It involves seven stages which include the
The planning framework 65
measurement and specification of needs and priorities;
the setting of aims and objectives; decisions on the
best way of achieving aims; the identification of
resources; the planning of evaluation methods and the
establishment of an action plan followed by action.
Examples are given of aims, objectives and action
plans, and exercises are provided on setting aims and
objectives and using the planning framework to turn
ideas into action.
This chapter is about planning and evaluation at the

level of your daily work in health promotion. It
provides a basic framework for you to use to plan
and evaluate your health promotion activities,
whether you work with clients on a one-to-one or
group basis, or undertake specific projects or
programmes.
The Planning Process
Planning is a process that, at its very simplest,

should give you the answers to three questions:
1. What am I trying to achieve? This question is
concerned with identifying needs and
priorities, then with being clear about your
specific aims and objectives.
2. What am I going to do? This can be helpfully
broken down into smaller steps:
– Select the best approach to achieving your start at Stage 6, with a basic idea of a health promo-
aims. tion intervention. Thinking more about it may lead
– Identify the resources you are going to use. you to clarify exactly what your aims are (Stage 2).
– Set a clear action plan of who does what and Next, you might think about what resources you
when. are going to need (Stage 4) and realise that you do
3. How will I know whether I have been not have enough time or money to do what you had
successful? This question highlights the in mind, so you go back to Stage 2 and modify your
importance of evaluation and the integral part aims. Then you think about the best way of achiev-
it plays in planning health promotion ing your aims (Stage 3) and work out an action plan
interventions. It should not be an afterthought (Stage 6). After that, you start to think seriously
or left too late to capture the information you about how you will know whether you are success-
need. ful (Stage 5) and you put your evaluation plans into
your action plan (Stage 6 again). In effect, you are
The planning process has been put together in the continually reviewing and improving your plan,
seven-stage flowchart in Fig. 5.1. The arrows on the using the framework appropriately to help you
flowchart lead you round in a circle. This is because, keep on course.
as you carry out your plan and evaluation, you will Planning takes place at many levels. If you are
probably find things that make you re-think and embarking on a major project, you will need to take
change your original ideas. For example, things you time to plan it in depth and detail. If you are simply
might want to change could include: working on a planning a short one-to-one session with a client
need you found you had overlooked; scaling down you will still need to plan, and to go through all the
your objectives because they were too ambitious; or stages, but the process might be quick and may not
changing the educational or publicity materials even be written down.
because you found that they were not as useful or For example, a chiropodist seeing a patient with
effective as you had hoped. The direction of the a foot care problem may identify that the patient
arrows is anticlockwise, but in reality planning is needs knowledge and skills in cutting toenails cor-
not always an orderly process. You may actually rectly. They decide that their aim is to give the
1. Identify needs and priorities
2. Set aims and objectives
3. Decide the best way of achieving the aims
4. Identify resources
5. Plan evaluation methods
6. Set an action plan
7. ACTION! Implement your plan, including your evaluation
Fig. 5.1 A flowchart for planning and evaluating health promotion.

Chapter 5 Planning and evaluating health promotion 65
patient basic information and training on this. They them as forming a hierarchy as in Fig. 5.2. At the
will know if they have been successful by getting top of the hierarchy are words that tell you why
feedback from the patient about how they managed your job exists, such as your job purpose or remit,
next time they see them. They identify an informa- or your overall mission. In the middle of the hier-
tion leaflet that they can give the patient as re archy are words that describe what you are trying
inforcement. They decide on an action plan of to do in general terms, such as your goals or aims.
explanation, demonstration and then get the patient At the bottom of the hierarchy are words that
to practise. They review the patient’s toenail cutting describe in specific detail what you are trying to do,
skills next time they see them, reinforcing or cor- such as targets or objectives.
recting as necessary. All this planning takes place It is worth noting that objectives can be of differ-
inside the chiropodist’s head, and is an integral part ent kinds. Health objectives are usually expressed as
of their everyday professional practice. the outcome or end state to be achieved in terms of
health status, such as reduced rates of illness or
death. However, in health promotion work objec-
The Planning Framework tives are often expressed in terms of a step along
the way towards an ultimate improvement in the
Stage 1: Identify Needs and health of individuals or populations, such as
Priorities increasing exercise levels.
In health education work, educational objectives
How do you find out what health promotion is
are framed in terms of the knowledge, attitudes or
needed? If you think you already know, what are
behaviour to be exhibited by the learner. Objectives
you basing your judgement on? Who has identified
can also be in terms of other kinds of changes, for
the need: you, your clients or someone else? Iden-
example a change in health policy (introducing a
tifying need is a complex process, which is looked
healthy eating policy in the workplace) or health
at it in depth in the next chapter.
promotion practice (providing health information
See Chapter 6. in minority ethnic languages).
You may have a long list of health promotion See the section below on setting educational objectives.
needs you would like to respond to, so another
The term target is increasingly used in health
issue is how to establish your priorities. Again, this
promotion. Targets usually specify how the achieve-
is discussed in detail in the next chapter, but an
ment of an objective will be measured, in terms of
important point is that you must have a clear view
quantity, quality and time (the date by which the
about which needs you are responding to, and what
objective will be achieved). So a health target can be
your priorities are.
defined as a measurable improvement in health
status, by a given date, which achieves a health
Stage 2: Set Aims and Objectives
objective. This is the approach used in national
People use a range of words to describe statements strategies for health, such as Choosing Health: Making
about what they are trying to achieve, such as aims, Healthier Choices Easier (Department of Health
objectives, targets, goals, mission, purpose, result, (DoH) 2004) and in the National service frameworks
product, outcomes. It can be helpful to think of (http://www.dh.gov.uk). An example of targets
Purpose
Aim Aim Aim
Objective Objective Objective Objective Objective Objective Objective Objective Objective
Fig. 5.2 A hierarchy of aims.

and ways of measuring progress can be found in

EXERCISE 5.1 Clarifying your purpose, aims and
the Delivering Choosing Health: Making Healthier objectives
Choices Easier (DoH 2005).
Read this example of a health promoter’s purpose, aims
There is more about national strategies and targets in and objectives.
Chapter 7, section on national public health strategies. Mark is a health promoter working for a local
The objectives are framed as health objectives, and authority. His purpose is to reduce inequalities in health
the targets are framed as health targets (changes in in the population living and working in the borough. To
rates of death or illness by a specific date), behaviour do this, one of his aims is to improve levels of health
targets (such as changes in population rates of knowledge of the black and ethnic minority groups.
smoking or drinking by a specific date) or progress One of his objectives is to improve access to health
measures (such as the number of people attending a information through the use of videos. He sets a target
smoking cessation service and the number setting of having a selection of ten health videos in six
a date when they plan to stop smoking). languages available in 25 shops within 4 months.
When you plan health promotion initiatives, you Now:
need to set aims, objectives and targets or goals and 1. Thinking of your own job, write down what you
outcomes. believe to be its mission or purpose.
Your aims (or aim, as there does not have to be 2. Then give an example of one of the health
more than one) are broad statements of what you promotion aims you are trying to achieve.
are trying to achieve. Your objectives are much 3. Finally, give an example of an objective you are
more specific, and setting these is a critical stage in trying to achieve, in fulfillment of the aim you
the planning process. selected.
Objectives are the desired end state (or result, or If you can’t find an example from your practice, make
outcome) to be achieved within a specified time up an example of what you would like to do if you had
period. They are not tasks or activities. Objectives the opportunity.
should be as follows:
● Challenging. The objective should provide you
with a health promotion challenge in relation to
what needs to be achieved. think it through further, and ask ‘Why produce a
leaflet? What am I aiming to achieve by producing
● Attainable. On the other hand, it should be
the leaflet?’ It then becomes clearer that the aim is
both realistic and achievable within the
to improve patient compliance with dietary treat-
constraints of your situation.
ment, and one of the objectives is to improve
● Relevant. It should be consistent with the aims
patients’ understanding of their dietary instruc-
of the organisation and with the overall aims of
tions. The action is to produce the leaflet. The
your job.
importance of actually thinking through your aims
● Measurable. You should try to identify and objectives in this way is that it helps you to be
objectives that are measurable, for example absolutely clear about why you are doing some-
specifying quantity, quality and a time when thing, not just what you are doing. Failure to think
they will be achieved. For instance (using the through this stage means that health promoters
example in Exercise 5.1), an objective of ‘to waste time and energy proceeding with what
improve access to health information through seems like a good idea only to realise, too late, that
the use of videos…’ has been improved by what they are doing is not actually achieving what
working out the appropriate number of videos they want.
and languages, and then specifying the target
as ‘to have ten videos in six languages…’
Setting educational objectives
It is sometimes difficult to distinguish between
aims, objectives and action plans. For example, a If your health promotion activity is based on a
dietician who wants to improve the information health education approach, it is useful to plan in
they give to patients may describe their aim as ‘to terms of educational objectives.
produce an information leaflet’ but this is also their Educationalists traditionally often think of objec-
objective and their action plan. The answer is to tives (sometimes called learning outcomes) in terms
of what the clients will gain. Furthermore, the ● The objective of changing the parent’s
objectives are considered to be of three kinds: what erroneous belief that sugar is essential to give
the educator would like the clients to know, feel and their child energy, and relieving their anxiety
do as a result of the education. In the language of that their healthy child’s food fads may cause
the educationalist, these may be referred to as cog- serious ill health.
nitive, affective and behavioural objectives. ● The objective that the parent learns what to do
at meal times when her child has a tantrum
Objectives about ‘knowing’ about eating.
These are concerned with giving information, To summarise the key points about setting aims and
explaining it, ensuring that the client understands objectives:
it, and thus increasing the client’s knowledge: for ● The focus is on what you are trying to achieve.
example, explaining the weight loss advantages of ● Be as specific as possible. Avoid vague or
increasing exercise levels to someone who is obese. subjective notions of what you want to achieve.
Here the objective would be to develop in the client
● Express your objectives in ways that can be
an understanding of the value of exercise with
measured. How much? How many? When?
regard to their weight loss programme to enable
● Do not get bogged down in terminology. It
them to make informed choices in terms of their
does not matter whether you talk about goals,
weight loss strategies.
aims, objectives, targets or outcomes. The key
principle is to be very clear about what you are
Objectives about ‘feeling’ trying to achieve.
These objectives are concerned with attitudes,
In order to practise setting aims and objectives,
beliefs, values and opinions. These are complex
undertake Exercise 5.1 and Exercise 5.2.
psychological concepts, but the important feature to
note now is that they are all concerned with how
people feel. Objectives about feelings are about
clarifying, forming or changing attitudes, beliefs, Stage 3: Decide the Best Way of
values or opinions. In the example above, when the Achieving the Aims
health promoter is educating a client about exercise Occasionally, there might be only one possible way
and weight loss, in addition to the knowledge of accomplishing your aims and objectives. Usually,
objective, there may be an objective about helping however, there will be a range of options. In Case
the client to explore their attitude towards exercise study 5.1 Jim has a number of options about how
and any values, beliefs or opinions that might be to achieve his objective of increasing the sun safety
forming a barrier to increasing exercise levels. measures being taken by the school and the chil-
dren. He could write to the schools or to parents of
Objectives about ‘doing’ school-age children, he could hand out leaflets at
These objectives are concerned with a client’s skills school gates, he could lobby parents to take up the
and actions. For example, teaching a routine of cause, he could find out if there are any school
aerobic or yoga exercises has the objective that governors’ meetings and ask to speak at them, he
clients acquire practical skills and are able to do could conduct a sun safety campaign in the local
exercise-related specific tasks. media, he could write an article on the issue of sun
In the health education approach to health pro- safety in school playgrounds for the education jour-
motion, a combination of the knowing, feeling or nals that teachers read, or he could try to meet each
doing educational objectives is usually required. Head Teacher face-to-face. Or he could do two or
For example, when a health visitor is advising a more of these together.
parent about feeding their toddler, they may be Health promoters such as Jim in Case study
planning to achieve the following objectives within 5.1 and Sue in Case study 5.2 are faced with the
three home visits: problem of how to identify the best strategy for
● The objective of ensuring that the parent achieving their objectives. Factors to consider
knows which foods constitute a healthy eating include:
programme for their child and which are best ● Which methods are the most appropriate and
given in restricted amounts. effective in meeting your aims and objectives?
● Which methods will be most acceptable to the

CASE STUDY 5.1
individual or population group?
Jim is an environmental health officer. His project is ● Which methods will be easiest?
to tackle sun safety in schools. This fits in with the ● Which methods are cheapest?
overall purpose of his job, which is to ensure safer ● Which methods do you find comfortable to
environments. Jim works out that his aim is to work use?
with local schools to set up a scheme that will result
in sun safety measures being taken by the school and There is more about evidence for success, cost-
the children. He researches the subject in detail, effectiveness and value for money in Chapter 7, and Part
looking at the results achieved from similar projects 3 of this book covers how to use these methods to
and working out how much time and money it is develop the necessary competency.
likely to take. He then decides that it is reasonable to Looking at the first of these questions about which
set his objective as follows: methods are most appropriate and effective for
■ Within 6 months to have raised awareness of the
feasibility and advantages of developing shaded
play areas with 10 primary schools, and worked
with at least five to set up shaded areas. CASE STUDY 5.2
Sue is a nurse specialising in coronary care. Her
project is to run patient education programmes so
that discharged patients know how to look after
themselves. This fits in with the overall purpose of
her job, which is to care for patients while they are
in hospital, and maximise their chances of a healthy
EXERCISE 5.2 Setting aims and objectives life following discharge.
Sue decides that her aim is that patients will have
Yewtree scheme participated in a cardiac rehabilitation programme for
The three practices at Yewtree Health Centre have post-heart attack patients. Her objectives are:
agreed to establish physical activity assessment sessions, ■ That every patient, before leaving hospital, knows
backed up by a display in the shared waiting area, with what they are advised to do about diet, exercise,
the aim of reducing the incidence of coronary heart smoking and stress control.
disease in the practice populations. ■ That every patient will be confident and
The detailed objectives are: competent to put this advice into practice.
1. To raise the users’ awareness of the link between ■ That every patient, and their carers and relatives,
inadequate exercise and coronary heart disease, will have had an opportunity to discuss questions
and the part which individuals can play in and anxieties with a qualified member of the staff.
reducing their own vulnerability to the disease. Sue’s programme is a continuous course of group
2. To assess, and advise about, individuals’ physical sessions each week, with each session focusing on a
fitness levels and help them to prepare an specific issue. So each individual session also has a
appropriate exercise action programme based on set of objectives. Objectives for the session on ‘Eating
those results. well when you go home’, for example, include:
3. To monitor and evaluate, on a continuing basis, ■ Patients will understand the basic principles of a
the effectiveness of the fitness testing, in respect healthy diet: low fat, low salt, low sugar and high
of the resources involved and the reduction in fibre.
vulnerability to heart disease. ■ Patients will know which foods they can eat in
Ask yourself the following questions: unlimited amounts, which they should restrict and
1. Do the objectives match the characteristics of which they should avoid.
objectives described above? Are they challenging, ■ Patients will know what their ideal weight should
attainable, as measurable as possible and be.
relevant? ■ Patients who are overweight will have devised a
2. How would you suggest changing the objectives? personal weight loss plan.
your aims, there is an accumulated body of evi- You may have decided on more than one of these
dence that helps to identify effective methods for categories of aims. For example, the inputs that con-
particular aims at the National Institute for Health tribute towards changing the behaviour of individ-
and Clinical Evidence (NICE) (http://www.nice. uals can be complemented by societal changes, so
org.uk) and at the Cochrane Database of Syste that together they are more effective than either
matic Reviews (http://www.cochrane.org). (See intervention alone by creating synergy. So, for
also http://www.who.int.) Table 5.1 identifies the example, to reduce the over-consumption of alcohol
range of aims, grouped into categories, and the by young people, you could:
appropriate and effective methods for achieving ● Provide health education about alcohol as part
them. This provides a general guideline, to which of schools’ personal and social education
there may be exceptions. programmes.
● Provide educational rehabilitation programmes
for young drink-drive offenders.
Table 5.1 Aims and methods in health ● Work with young people to promote the social
promotion acceptability of consuming nonalcoholic drinks.
● Lobby for an increase in alcohol taxation or for
AIM APPROPRIATE METHOD increasing the age at which young people can
buy alcohol.
Health awareness goal Talks
Raising awareness, or Group work The example in Fig. 5.3 shows the range of aims and
consciousness, of Mass media methods that might be used to promote healthy
health issues Displays and exhibitions eating. These may not all be used by a health pro-
Campaigns moter at any one time, but they are given here to
Improving knowledge One-to-one teaching illustrate the range of possibilities.
Providing information Displays and exhibitions
Written materials
Mass media (including the Internet) Stage 4: Identify Resources
Campaigns
Group teaching What resources are you going to use? You have to
Self-empowering Group work establish what resources you are going to need and
Improving self- Practising decision making what are already available, what additional
awareness, Values clarification
self-esteem, Social skills training
resources you are going to have to acquire, and
decision making Simulation, gaming and role play whether you will need extra funding. A number of
Assertiveness training different kinds of resources can be identified.
Counselling
Changing attitudes Group work
and behaviour Skills training Professional input
Changing the lifestyles Self-help groups
Your experience, knowledge, skills, time, enthusi-
of individuals One-to-one advice and instruction
Group or individual therapy
asm and energy are vital resources. It helps to
Written material identify all the other professional and lay people
Social marketing approach with something to offer. This may include col-
Societal/environmental Positive action for under-served leagues and others in your professional networks
change groups with relevant expertise that can advise and help
Changing the physical Lobbying for fiscal and legislative you make your plans, clerical and secretarial staff
or social change
that can help with administration, technicians,
environment Pressure groups
Community development graphic designers and artists who can help with
Community-based work exhibitions, displays and teaching/publicity mat
Advocacy schemes erials.
Environmental measures
Planning and policy making
Organisational change Your client or client group
Enforcement of laws and
These are another key resource. Clients may have
regulations
knowledge, skills, enthusiasm, energy and time,
AIM: Health awareness
Possible methods:
• articles in local newspapers
• exhibition on healthy eating and weight control, including
weighing machine, height/weight charts, information on
physical activity and healthy eating cookery demonstrations
• posters on nutritional themes in health service premises
• programmes on local radio
AIM: Social change AIM: Knowledge
Possible methods: Possible methods:

• working with parents and teachers to encourage • nutrition teaching as part of science
the sale of nutritious foods in school tuck shops and health education in schools
• working with NHS caterers to devise lower fat, • advice and help for patients from
higher fibre hospital food for patients and staff health professionals in clinical settings
• lobbying food manufacturers to include • talks on aspects of nutrition to community groups
clearer information on food labels
PROMOTION OF
HEALTHY EATING
AIM: Behaviour change AIM: Self-awareness,

attitude change
Possible methods: decision-making
• groups for healthy eating and weight control
• individual support for patients on special diets Possible methods:
• groups and cooking clubs to develop skills • informal group work with antenatal clients and
and confidence in preparing healthier meals pre-retirement groups
for families • work with individual clients on whether to lose
• recipes and ideas for nutritious packed weight, cut down on salt, or increase fibre
lunches for schoolchildren
Fig. 5.3 Aims and methods for the promotion of healthy eating.
which can be used and built upon. In a group,

People who influence your client or
clients can share their knowledge and previous
client group
experience and in this way help each other to learn
and change. An ex-client can be a very valuable These may include clients’ relatives, friends, volun-
resource too. For example, someone who has suc- teers, patients’ associations and self-help groups. It
cessfully lost weight, an ex-smoker or a person who may also be possible to harness the help of signifi-
has undergone a particular health-related experi- cant people in the community who are regarded as
ence can be a great help to clients who are grappling opinion leaders or trendsetters, such as political
with similar problems and experiences. figures, religious leaders or media celebrities.
Existing policies and public process of assessing what has been achieved and
health strategies how it has been achieved. It means looking critically
at the activity or programme, working out what
National and local policies and strategies for public were its strengths and its weaknesses, and how it
health are useful to locate in terms of the work that could be improved.
you are planning. If, for example, you are planning The judgement can be about the outcome (what
to develop an intervention to help prevent the has been achieved): whether you achieved the
spread of sexually transmitted infections and HIV objectives which you set. So, for example, you
and reduce unwanted pregnancies, find out if there should judge whether people understood the rec-
is already a policy on promoting sexual health in ommended limits for alcohol consumption as a
your area. Also find out whether your work fits into result of your sensible drinking education, whether
the National Strategy for Sexual Health and HIV (DoH people in a particular community became more
2001) and use the associated national guidance and articulate about their health needs as a result of
evaluation reports to inform your work (such as your community empowerment work, whether
Medical Foundation for AIDS and Sexual Health you achieved media coverage for your health
2008). campaign, etc.
National and local plans, which your work could Judgements can also be about the process (how it
contribute to, are discussed in Chapter 7. has been achieved): whether the most appropriate
methods were used, whether they were used in the
most effective way and whether they gave value for
Existing facilities and services money. So, for example, you could consider whether
Find out what relevant local facilities already exist the video-based discussion you used in your teach-
and whether they are fully utilised; for example, ing programme was the best teaching method to
sports centres offering facilities for exercise and use, whether the community development approach
local classes or groups on cooking for healthy you chose was the most appropriate one in the cir-
eating. cumstances, or whether you would have achieved
more public awareness with less money if you had
opted for a media stunt with possible free news
Material resources coverage rather than an expensive advertising and
These might include leaflets, posters and display/ leaflet campaign.
publicity materials or, if you are planning health Key terms often used in discussions about evalu-
promotion involving group work, you need ation are defined in the Glossary at the end of this
resources such as rooms, space, seats, audiovisual book (see also Green & South 2007).
equipment and teaching/learning materials.
Why evaluate?
Stage 5: Plan Evaluation Methods
You need to be clear about why you are evaluating
How will you measure success and know whether
your work, because this will affect the way you do
your health promotion is successful? Sophisticated
it and the amount of effort you put in. Some reasons
methods are required to evaluate large-scale health
could be:
promotion interventions. However, this should not
deter health promoters; less complex methods of ● To improve your own practice: next time you
evaluating the everyday practice of health promo- deliver a similar intervention, you will build on
tion can, and should, be used routinely. your successes and learn from any mistakes.
● To help other people to improve their practice:
if you disseminate your evaluation, it can help
What is meant by evaluation? others improve their practice as well. It is vital
Evaluation is about making a judgement about the to publicise failures as well as successes.
value of a health promotion intervention, whether ● To justify the use of the resources that went
it is a health education programme, for example, a into the intervention, and to provide evidence
community project or an awareness-raising cam- to support the case for doing this type of health
paign to change local policy. Evaluation is the promotion in the future.
● To give you the satisfaction of knowing how intervention was designed to achieve and might
useful or effective your work has been; in other have included changes in people’s knowledge or
words, for your own job satisfaction. behaviour or changes in policies or ways of working.
● To identify any unplanned or unexpected Long-term health promotion projects may also have
outcomes that could be important. For example, objectives about changes in health status. The fol-
a publicity campaign to deter young people lowing list indicates the kinds of changes that may
from taking drugs could have the opposite be reflected in your objectives, and what methods
effect by unwittingly glamorising drug-taking you might use to assess or measure those changes.
and making it appear to be a more common
activity than it really is. Changes in health awareness can be assessed by:
● Measuring the interest shown by consumers,
for example how many people took up offers
Who is the evaluation for? of leaflets, how many people enquired about
Who will be using your evaluation data? The preventive services, how many people visited
answer to this affects what questions you ask, how a website.
much depth and detail you go into and how you ● Monitoring changes in demand for health-
present the information. related services.
If you are solely assessing how well a health ● Analysis of media coverage.
promotion intervention went, for your own benefit ● Questionnaires, interviews, focus group
so you can change it appropriately next time you discussion, observation with individuals or
run a similar session, you will simply make a judge- groups.
ment on how you think it went based on your
observation and the clients’ reactions, and make a Changes in knowledge or attitude can be assessed by:
few notes. But if you are writing a report for your ● Observing changes in what clients say and do:
manager or for a body that you want to fund the does this show a change in understanding and
work, you need to think through what questions attitude?
those people will expect to be answered, and how ● Interviews and discussions involving question-
much detail they will want. and-answer between health promoter and
For example, a group of health visitors evalua clients.
ting a pilot scheme for a telephone advisory service
● Discussion and observation on how clients
at evenings and weekends need an evaluation
apply knowledge to real-life situations and how
report after 6 months for their manager, who is
they solve problems.
funding the service. What will the manager need to
● Observing how clients demonstrate their
know? At the very least, they will probably need a
clear indication of the use made of the service. This knowledge of newly acquired skills.
might include how many people used it, the char- ● Written tests or questionnaires that require
acteristics of the users (for example, whether they clients to answer questions about what they
were first-time parents), how much it was used, know. The results can be compared with those
what sort of issues people rang about, what the of tests taken before the health promotion
clients gained from it and how much it cost. It activity or from a comparable group that has
would be helpful for the health visitors to ask their not received the health promotion.
manager what evaluation data will be required at
the planning stage of the project, so that the appro- Behaviour change can be assessed by:
priate data can be collected from the start. ● Observing clients’ behaviour.
● Recording behaviour. This could be based on
records, such as numbers attending a smoking
Assessing the outcome
cessation clinic or clients keeping a diary which
Looking first at outcome measures, which are called is used at the end to assess behaviour change.
summative evaluation, you need to go back to the It could be a periodical inventory, such as a
objectives you set, and plan how you are going follow-up questionnaire or interview to check
to determine whether you have achieved the on smoking habits 6 and 12 months after
objectives. Objectives are about the changes the attending the smoking cessation clinic. Records
of client behaviour can be compared with those judgements about effectiveness and efficiency. Was
of comparable groups in other areas, or with it done as cheaply and quickly as possible? Was the
national average figures. quality as good as you wished? Were the appropri-
ate methods and materials used? You may, for
Policy changes can be assessed by: instance, achieve your objectives, but in a time-
● Policy statements and implementation, such as consuming, costly or inefficient way, so it is impor-
increased introduction of healthy eating choices tant to evaluate the process as well as identify
in workplaces and schools. whether you have achieved your desired outcome.
● Legislative changes, such as increased Formative evaluation can be ongoing so that
restriction on alcohol advertising. changes can be made to the intervention if it is
● Changes in the availability of health promoting
found not to be working while it is in the process
products, facilities and services such as exercise of delivery.
prescription schemes. How are you going to assess the process? There
are key aspects to process evaluation which involve
● Changes in procedures or organisation, such as
measuring the input, self-evaluation by asking
more time being given to patient education.
yourself questions and getting feedback from other
people.
Changes to the physical environment can be
assessed by: Measuring the input
● Measuring changes in such things as air quality,
This is essential if you are going to make judge-
traffic or pedestrian flows or the amount of ments about whether the outcome was worthwhile.
open green space available to the public within You need to record everything that went into your
a defined area. health promotion activity, in terms of time, money
and materials. Then you can make an informed
Changes in health status can be assessed by: judgement about cost–benefit and whether the
● Keeping records of simple health indicators outcome justified the cost.
such as weight, blood pressure rates, pulse
rates on standard exercise, or cholesterol levels. Self-evaluation
● Health surveys to identify larger scale changes Ask yourself ‘What did I do well?’, ‘What would I
in health behaviour or self-reported health like to change?’ and ‘How could I improve that next
status. time?’ All kinds of health promotion approaches
● Analysis of trends in routine health statistics can be subjected to process evaluation, whether it
such as infant mortality rates or hospital is a one-to-one health education intervention with
admission rates. a client, facilitating a self-help group, undertaking
It will be seen from this list that common evaluative community empowerment work, developing and
methods are the generation of data from obser implementing a health policy or lobbying for organ-
vation, holding discussions and distributing ques- isational and structural changes.
tionnaires and data analysis of health and other An important point to note about self-evaluation
records. is the need for a balanced objective critique which
highlights both the positive and the negative
Help with these is in Chapter 7, section on doing your aspects. Identify the things that have worked and
own small-scale research, and Part 3 of this book. look for constructive ways forward about things
that could be improved.
Assessing the process Feedback from other people
Assessing intervention processes, or formative Giving and receiving feedback is an essential skill
evaluation, is an important aspect of a comprehen- for every health promoter. Getting feedback from a
sive evaluation of health promotion activities trusted colleague on your health promotion initia-
(see Parry-Langdon et al 2003 for an overview tives is a valuable form of peer evaluation. Asking
of process evaluations in health promotion). for, and getting, feedback from your manager
This requires examining what went on during should be part of the regular monitoring of your
the process of implementation, and making performance.
See section in Chapter 10 on asking questions and at particular points in time. The schedule should
getting feedback. specify deadlines that must be met by the people
Obtaining feedback from the clients or users involved. Another way of breaking down a large
themselves should also be part of assessing the project is by milestone planning. This is different
process of every intervention. The important thing from key events planning: instead of listing events,
is to encourage a nonjudgemental atmosphere of it lists a series of significant dates at fixed intervals
openness and honesty. It can be done in many ways; (the milestones) and shows what must have hap-
simply observing clients and users accurately is an pened by each of them. Box 5.1 illustrates both
important tool. Do they look anxious or relaxed? types of action plans.
Do they look interested and alert or bored and For more discussion about the skills of project
detached? You can also ask for feedback in such management, see Chapter 8, section on managing
ways as a suggestions box, through noting any project work.
spontaneous verbal feedback you receive or through
asking questions.
Stage 7: Action!
Stage 6: Set an Action Plan This is the stage in which you actually do your
Now that you know: health promotion, remembering to evaluate the
process as you go along.
● what you are trying to achieve and have
Exercise 5.3 gives you the opportunity to apply
identified the best way to go about it
this planning framework.
● how to evaluate it
To summarise, the planning process consists of a
● what resources you need series of stages which enable you to more system-
you can get down to planning in detail exactly what atically organise your health promotion work by
you are going to do. This means writing a detailed focusing on key questions around What? Why?
statement of who will do what, with what resources When? Who? Where? and How? Useful additional
and by when. reading to support planning and evaluation
It is helpful, especially if you are tackling a large are Rootman et al (2001), Tones & Tilford (2001),
project, to break down your plan into smaller, man- Thorogood & Coombes (2004), Tones & Green
ageable elements. One way of doing this is by think- (2004), Nutbeam & Bauman (2006) and Green &
ing in terms of key events. Draw up a schedule South (2007). Finally, the National Social Marketing
showing the key events that are planned to happen Centre also provides a planning model (see Chapter
BOX 5.1 Action plans

A key events plan drawn up by a health promoter who A brief milestone plan for the early stages of setting up a
plans to set up a health stall in a local supermarket could community health project could be like this, in a
look like this: framework of 3-monthly ‘milestones’:
1. Discuss with my manager at October meeting.
2. Identify support from colleagues by November. January–March 2003 Steering group agrees job
3. Approach supermarket manager (before Christmas description for community
rush); agree space and times. health worker. Job
4. Convene planning group of colleagues in January advertised.
to sort out who will do what and when, and By end of June 2003 Interviews; appointment made.
evaluate plans, and identify the resources Community worker takes up
required. post.
5. Set up first stall in March. By end of September Community worker induction
2003 programme completed.
By end of December First progress report to
2003 Steering Group.
EXERCISE 5.3 Ideas into action: planning a health promotion project

Work alone or in a small group. 2. The best way of achieving my aims
Think of an area of health promotion where there is an Think of all the ways in which you could achieve
identified need, and it is within the remit of your job to your aims and identify the best way.
meet that need. It could be an established area of work 3. Resources
such as antenatal education, smoking cessation, teaching Identify the resources you already have available
food hygiene, or an area of new work you would like to and any extra ones you will need.
tackle. If you are not currently in a job which involves 4. Evaluation
health promotion, think of a health-related project you Ask yourself ‘How will I know if I am succeeding?’
would like to tackle in your personal life, or a project for Identify how you will evaluate both the process and
any voluntary/community group you are associated with, outcome of your work.
or just imagine what you would like to do if you had the 5. Action plan
opportunity. Identify who will do what, with what resources, and
Work through the following stages of the planning by when.
cycle. Start by writing each of the following headings at Be aware that when you are thinking about one section,
the top of a separate large sheet of paper, and then work it may have implications for the others, so you may find
through them: yourself going back to modify and refine what you have
1. Aims and objectives already written.
Ask yourself ‘What am I trying to achieve?’ Identify
your broad aim, or aims, then be more specific and
identify your objectives.
3) and tools for planning on their website (http:// clearly set and methods for achieving aims and
www.nsms.org.uk). objectives are carefully considered in the context of
available resources.
PRACTICE POINTS ■ Evaluation is an important component of the
planning process and evaluation methods should be
■ Health promotion work benefits from being planned formative and measure the process, and summative,
and evaluated in a systematic way. measuring the outcome of health promotion
■ A planning cycle should ensure that needs and interventions.
priorities are identified, aims and objectives are
References
Department of Health 2001 Better Green J, South J 2007 Evaluation. of health promotion interventions.
prevention, better services, better Berkshire, Open University Press. Policy & Politics 31(2): 207–
sexual health – the national Medical Foundation for AIDS and 216.
strategy for sexual health and Sexual Health 2008 Progress and Rootman I, Goodstadt M, Hyndman B
HIV. London, The Stationery priorities – working together for et al (eds) 2001 Evaluation in health
Office. higher quality sexual health. promotion: principles and
Department of Health 2004 Choosing London, MedFASH. perspectives. WHO Regional
health: making healthier choices Nutbeam D, Bauman A 2006 Publications, European Series, No
easier. London, The Stationery Evaluation in a nutshell: a practical 92. Denmark, World Health
Office. guide to the evaluation of health Organization.
Department of Health 2005 Delivering promotion programs. Maidenhead, Thorogood M, Coombes Y 2004
choosing health: making healthier McGraw-Hill Medical. Evaluating health promotion:
choices easier. London, The Parry-Langdon N, Bloor M, Audrey S, practice and methods. Oxford,
Stationery Office. Holliday J 2003 Process evaluation Oxford University Press.
Tones K, Green J 2004 Health Websites http://www.nice.org.uk

promotion: planning and strategies. http://www.cochrane.org/reviews http://www.nsms.org.uk
London, Sage. http://www.dh.gov.uk/en/ http://www.who.int
Tones K, Tilford S 2001 Health Healthcare/DH_082787
promotion – effectiveness, efficiency
and equity, 3rd edn. Cheltenham,
Nelson Thornes.
77
Chapter 6
Identifying health promotion needs
and priorities
Summary
Chapter Contents
This chapter begins with an analysis of the concept
Concepts of need 78 of need. This is accompanied by an overview of
essential factors for you to consider when identifying
Need, demand and supply 79
health promotion needs. These include the scope
Identifying health promotion needs 79 and boundaries of professional remits; the difference
between reactive and proactive choices and the
Finding and using information 81
importance of placing the people who are the targets
Assessing health promotion needs 83 and users of health promotion at the centre of
the needs identification process. This discussion is
Setting health promotion priorities 84
supplemented with an exercise on the user friendliness
of services. In the next section on finding and using
health information, types and sources of information
are identified and exercises included on gathering and
applying information. This is followed by a framework
for assessing health promotion needs, with a case
study and an exercise. In the final section there is a
focus on priority setting, with exercises on analysing
the reasons for health promotion priorities and on
setting priorities.
Many organisations at different levels have a role

in identifying public health needs, including those
needs that can be addressed by health promotion
interventions. These range from international agen-
cies, such as the World Health Organization (WHO),
national organisations, such as government
departments, to organisations at local level, such
as primary care trusts (PCTs).
See Chapter 4 for information on the range of agencies
with a public health and health promotion role, Chapter
7 for national and local health strategies, and Chapter
16 for making and implementing national and local a need. For example, a dietitian may identify a
health strategies. certain level of nutritional knowledge as the desir-
able standard for her client and defines a need for
The focus in this chapter is on the need for
nutrition education if her client’s knowledge does
interventions undertaken by health promoters
not reach that standard. This normative need is
working with individual clients, families, groups
based on the judgements of professional experts,
and communities.
which may lead to problems. One is that expert
Identifying the people who are intended to
opinion may vary over what is the acceptable
benefit from health promotion activities (sometimes
standard, and the values and standards of the
called target groups) is a complex process. These
experts may be different from those of their clients.
people may be referred to as users, which imply
Some normative needs are prescribed by law,
they use health promotion services such as smoking
such as food hygiene regulations (see Food Stand-
cessation groups. In some cases people receive
ards Agency 2006), or by national policy and related
help that they may or may not use, for example
guidelines and targets (see, for example, Depart-
receiving advice and information leaflets. Alterna-
ment of Health (DoH) 2009a).
tively, people may be called consumers, customers,
clients or patients if they are receiving their health
promotion via medical services, such as a coronary
rehabilitation service. Positive action may be neces-
2. Felt Need – Wants
sary to ensure that everyone has equal access to Felt need is the need that people feel; it is what they
services and can benefit from them. want. For example, a pregnant woman may feel the
Going one stage further and identifying and pri- need for (and want) information about childbirth.
oritising people’s needs is also a complex and dif- Felt needs may be limited or inflated by people’s
ficult process. Needs may exceed the finite resources awareness and knowledge about what could be
available to meet them so difficult choices may have available: for example, people will not feel the need
to be made. to know their blood cholesterol level if they have
Before looking further at how the needs of the never heard that such a thing is possible or know
users and receivers of health promotion can be met, about the potential risk of high blood cholesterol
it is worth considering what is understood by levels to health.
a need.
3. Expressed Need – Demands

Concepts of Need Expressed need is what people say they need; it is
felt need that has been turned into an expressed
It is useful to think of need in terms of: request or demand. Commercial weight-control
● the kinds of health problems which people groups and exercise classes are examples of
experience or are at risk from expressed need; they are provided in response to
● the requirements for a particular kind of health demand.
promotion response Not all felt need is turned into expressed need or
demand. Lack of opportunity, motivation or assert-
● the relationship between health problems and
iveness could all prevent the expression of a felt
the health promotion responses available.
need. Lack of demand, therefore, should not be
Bradshaw’s (1972) taxonomy of need was estab- equated with lack of felt need.
lished many years ago but it is still very useful in Expressed needs may conflict with a profes
distinguishing between four different kinds of need. sional’s normative needs. For example, a patient
may express a need for a course of individual pro-
fessional counselling as a result of experiencing a
1. Normative Need – Defined by
mental heath problem, but the resources may not
the Expert
be available for this type of health promoting
Normative need is a need defined by experts or service and normative needs and priorities may be
professionals according to their own standards; focused on other types of interventions to promote
falling short of those standards means that there is mental health.
Chapter 6 Identifying health promotion needs and priorities 79
4. Comparative Need Shape of Things to Come (NHS Confederation 2009)

which suggests that direct payments could result in
Comparative need for health promotion is defined enhanced health outcomes and positively change
by comparison between similar groups of clients, the nature of the patient–professional relationship.
some in receipt of health promotion and some not. The scheme is currently in a pilot phase so its effect
Those who are not are then defined as being in on the supply and demand for health promotion
need. For example, if Company A has an employee services is not yet known.
health policy covering stress at work and the provi- Measures to address the uneven supply and
sion of healthy food choices in the staff canteen and quality of health services have also included publi-
Company B does not, it could be said that there cation of national standards, in the form of the
is a comparative need for health promotion in national service frameworks (NSFs) that set out
Company B. This assumes that the health promo- the pattern and level of service which should
tion in Company A is desirable and ideal, which of be provided for major care areas such as mental
course it may not be. health and disease groups such as cancer (http://
www.dh.gov.uk). Local services are required to
work towards these standards. National bodies
Need, Demand and Supply also have a role in ensuring that the best value-
for-money services and treatment are provided
Over time, there has been debate over need, fairly wherever people live. The Care Quality
demand, supply and quality of health services and Commission (http://www.cqc.org.uk) is responsi-
other public sector services that relate to health pro- ble for ensuring good-quality services in the
motion, such as education. Levels and quality of NHS, and the National Institute for Health and
service can vary across the country, and between Clinical Excellence (http://www.nice.org.uk) pro-
GPs and hospitals even in the same neighbourhood, vides the evidence for clinical practice and health
resulting in what has been termed as a postcode promotion.
lottery (Kiss 2006). The need for services may be
similar or different, but supply is unevenly distrib-
uted and this results in significant health inequali-
ties (see, for example, Jaffa (2003) in relation to Identifying Health
mental health services, Cockcroft (2007) in relation Promotion Needs
to cancer care, and the BBC (2009) reporting varia-
tion in health visitor provision). How does a health promoter set about identifying
If demand outstrips supply it means that people people’s needs? There are three key areas it is useful
do not always get the access to the health services to think about first: the scope and boundaries of
they want, or that health professionals believe they your job; the balance between being reactive and
need. This issue of uneven provision also applies to proactive in your work; and the extent to which you
health promotion services, with different levels of are putting your clients first. Each of these is
provision in different geographical areas (Scriven addressed in turn.
2002, DoH/WAG 2005). The Institute of Healthcare
Improvement (IHI) has a range of tools to ensure
that demand matches supply (http://www.ihi.
The Scope
org), but nonetheless the problem arises because the
health services and other public bodies have a finite For some practitioners the task of identifying
pot of money to spend, so they have to prioritise. needs has already taken place. For example, dental
This can result in rationing (Campbell 2007, Klein hygienists working in a dental surgery with indi-
2007). To overcome the problems associated with vidual patients already have the clearly identified
rationing, the 2008 NHS Next Stage Review (DoH task of educating patients in oral hygiene. But they
2008a) endorsed NHS funding within personal may want to think carefully about how they can
health budgets. This new initiative of giving per- make their service as person centred and user
sonal health budgets to the general population (for friendly as possible. And they will certainly have to
more detail see DoH 2009b) coincides with an NHS identify and respond to the individual needs of
Confederation report Personal Health Budgets: the each patient.
Other workers, however, have more choice and service because of difficulties in getting staff to
scope in the range of health promotion activities work at weekends. However, numerous interna-
they can undertake. Health visitors and community tional policy directives, such as the seminal Ottawa
workers may have considerable scope, but the Charter (WHO 1986), and national strategies such as
degree of autonomy they have will vary according Choosing Health (DoH 2004), have emphasised the
to the policy of their managers and the resources need for more people-centred health promotion.
available. All health promoters will need some The core values that would be embedded in
competency in being responsive to the health pro- people-centred health promotion are:
motion needs of their clients, and will need to be ● empowerment
clear about the boundaries of their work: which
● participation
health promotion activities are within their remit to
● the central role of the individuals, family and
undertake and which are not, however desirable
they may be. For example, a family planning nurse community in any process of health
may be asked to undertake sex education with development
young people in schools, but is this within the ● equity and nondiscrimination.
boundaries of her job? The implications of these values are clear. People
have the right to participate in making decisions
Reactive or Proactive? about their health and should be enabled to do so.
The needs, wants and expectations of individuals,
It is useful to make an initial distinction between families and communities should be respected by
being reactive and being proactive when identifying health promoters and influence priority setting and
needs. Being reactive means responding or reacting the delivery of health promotion services. You can
to the needs and demands that other people make. measure how user friendly your services are by
Pressure from vested interest groups and the media undertaking Exercise 6.1.
may introduce bias into how needs are perceived, These values suggest that key characteristics of
and produce pressure to react. Being proactive people-centred health promotion might include the
means taking the initiative and deciding on the area following:
of work to be done. It may include rejecting the For individuals, communities and population groups:
demands of other people if these do not fit existing
● Access to clear, concise and intelligible health
policies and priorities.
information and education that increase health
See Chapter 3, section on analysing your aims and literacy and enable needs to be expressed.
values: five approaches. ● Equitable access to health including treatments,
Being reactive or proactive can be related to and psychosocial support.
the approaches to health promotion, which were ● Development of personal skills which allow
discussed in Chapter 3. Using a client-directed control over health and engagement with
approach means being reactive to consumers’ healthcare systems: communication, mutual
expressed needs, whereas using a medical or behav- collaboration and respect, goal setting, decision
iour change approach probably means being pro making, problem solving, self-care.
active. This is particularly true of preventive ● Supported involvement in health decision
medical interventions such as immunisation cam- making, including health policy.
paigns. In practice, there is usually a balance to be For health promotion practitioners and specialists:
struck between being reactive and proactive.
● Holistic understanding and approach to health
improvement.
Putting Users’ Needs First ● Respect for people and their decisions.
It is important to ask the questions about whose ● Recognition of the needs of people seeking to
needs should come first, the users or the providers improve their health.
of health promotion. There may be conflict between ● Professional and personal skills to meet these
the two: for example, users may want a family plan- needs: competence in promoting health,
ning service to be open on Saturdays to improve communication, mutual collaboration and
access but providers are unable to supply this respect, empathy, responsiveness, sensitivity.
EXERCISE 6.1 Using services that promote health or prevent ill health: user views
Find out about some services available locally, designed ■ Is public transport easily available/is there easy
for the public, staff and/or health students (whichever is access for parking your car?
relevant to you) that aim to promote health or prevent ill ■ Are the opening times convenient to you?
health. The public library, human resources department of ■ If there is a charge for the service, is it affordable
your employer, NHS trust or local council, for example, and good value for money?
may be able to provide information about what services ■ How are you welcomed at reception? Are you given
are available. These could include swimming facilities, all the information you need? Do you feel at ease?
exercise classes, the resources and information service of Are the staff friendly?
your local Public Health and Health Promotion ■ What do you think about the environment – is it
Departments or an NHS walk-in centre. safe, clean and comfortable?
Select one of these, appropriate and acceptable to you, ■ What do you think about the quality of the service
and visit it. Make notes about what happens and how to you received? Do you have any ideas about
make a service responsive to its users. how it could be improved? Will you use this
See also the section on working for quality in Chapter service again?
8 for information on quality in health promotion services. ■ What have you learnt as a service user which you
■ Is it easy to find out that the service exists? can now apply to health promotion practice?
■ Is it easy to locate, with clear signposting where
needed?
● Commitment and adherence to quality, There are a number of different kinds of informa-
evidence-based and ethical practice. tion you can access when identifying need.
● Team work, collaboration and partnership
across disciplines and with clients. Epidemiological Data
(Adjusted from http://www.wpro.who.int)
Let us now return to the central question: how Epidemiology is the study of the distribution and
are needs for health promotion identified? determinants of disease in communities. Epidemio-
logical data indicate how many people are affected
by a health problem, how many people die from a
particular health problem, and who are most at risk
Finding and Using Information within sex, age, ethnic, socioeconomic, occupational
or geographical groupings or perhaps by taking
The starting point for defining health promotion account of factors such as weight, smoking or
needs is information of various kinds from a range physical activity levels.
of sources. If you are gathering information on a Detailed discussion of the sources and limita-
local area for the first time, it would be helpful to tions of epidemiological data is outside the scope of
share the work, and the findings, with colleagues. this book, but for excellent texts on epidemiology
For example, health visitors may have done a see Bonita et al (2007) and Gordis (2008). The impor-
neighbourhood profile as part of their training; the tant point to make here is that epidemiological data
public health department in the local PCT will provide essential information on the health of the
probably have health data on the local population. population, the causes and risk factors related to ill
Gathering and updating all these different kinds of health and in doing this, the potential for preven-
information is an ongoing project for every health tion and health promotion.
promoter and sharing the task is a more efficient Mortality and morbidity data are collected
use of time. Working with colleagues needs to done nationally, and some data are also available on a
in conjunction with establishing links with local regional and local basis. Mortality data are con-
people, in order to ensure the active participation cerned with causes of death; morbidity data with
of users and receivers. types of illness and disability. Mortality data are
derived from death certificates; morbidity data

EXERCISE 6.2 Gathering local public health
from a wide range of sources, including medical information
records, sickness absence certificates, child health
records, returns of notifiable diseases, disability Ask your local NHS organisation, such as your local PCT
registers and many others. In addition, surveys (or equivalent in Scotland, Wales and Northern Ireland),
such as the government’s General Household for reports or data on the health status of your local
Survey (GHS) (http://www.statistics.gov.uk) and population. They may have information available on the
those carried out for research purposes provide a Internet. Some local data may also be available on
considerable amount of health information. national websites, such as http://www.dh.gov.uk, http://
Your local NHS organisation, such as a PCT, may www.statistics.gov.uk or http://www.ons.gov.uk. Browse
have information about the local population includ- through the data and see if you can find out, for your
ing mortality and morbidity data (such as hospital local population:
admission rates for particular conditions). This may ■ What are the major causes of death?
be broken down to the level of the population of ■ What are the major reasons for people to be
smaller areas such as electoral wards. It might be admitted to hospital?
helpful to compare data for the whole population ■ What are the major risk factors for ill health? For
and electoral ward data (for a neighbourhood) on, example, is there information on what percentage
for example: of people smoke in your local population?
■ How many people have had communicable
● the major causes of death
diseases (diseases caught from other people)
● the key causes of childhood admission to
such as measles or sexually transmitted
hospital
infections?
● the main conditions for which adults are ■ Which neighbourhoods or communities have the
admitted to hospital. poorest health?
Exercise 6.2 is designed to enable you to find out ■ What steps are being taken to prevent ill health
about local health information. and promote good health?
Can you find information on anything else to help you
in your health promotion work?
Lifestyle Data
An increasing amount of information about peo-
ple’s health-related behaviour and lifestyle, such as
physical activity, sexual behaviour, smoking and electoral ward data on social and economic factors,
drinking, is available on a national basis from such as:
survey data. See, for example, the SHEU surveys ● unemployment
(http://www.sheu.org.uk) which have up-to-date ● household amenities
data on the lifestyle of young people at school. ● income
There are active surveys that date back 32 years and ● ethnicity.
therefore act as valuable benchmarks. You may also
find that a local or regional NHS organisation has It is advisable to ask for figures that are as full and
done a lifestyle survey of your local population, recent as possible. Much information is obtained
and published the findings (see, for example, Jones from the national census, which takes place every
& Tocque 2005). 10 years. The last one was in 2001; information
from the analysis of the data is available at the
Office of National Statistics (ONS). The ONS has
an online facility which will allow you to search
Socioeconomic Data
for detailed information online (http://www.
The planning or information departments of neighbourhood.statistics.gov.uk). The next national
local councils should be able to help with infor census is planned for 2011.
mation about housing, employment, social class By setting illness data alongside social and eco-
and social/leisure/recreation/shopping facilities. nomic data, you may be able to see patterns that
Many produce summaries of census data. It might might inform your needs identification and priority
be helpful to compare district/borough/city and setting process. You may want, for example, to
determine if areas where people with less financial posing to have with local groups and individuals.
and other resources live are also likely to be the For example, if you plan simply to establish consul-
areas of poorest health. tation mechanisms, there may be hostility if local
people have played a stronger partnership role in
the past.
Professional Views
Public consultation and involvement are discussed in
The views of the wider public health workforce
detail in Chapter 15.
reflect experience and perceptions accumulated
over the years, which it would be foolish to ignore.
The groups involved may include patient and
What do other workers in your area, such as teach-
public involvement forums (DoH 2008b) and
ers, youth workers, social workers, GPs, health visi-
patient advice and liaison services (PALS; http://
tors, district nurses, environmental health officers,
www.pals.nhs.uk), local voluntary organisations
police officers, community workers and religious
and community groups such as self-help groups,
leaders consider the major health concerns?
black and minority ethnic groups, pensioners’
clubs, tenants’ associations, and a variety of local
advisory groups or planning subcommittees, in
Public Views
addition to groups of key clients such as parents.
Public sector organisations are now charged with Gathering views informally is useful but there
the responsibility of seeking the views of the com- are problems in ensuring accuracy and that subjec-
munities that they serve, but some organisations tive information is representative. However, these
have developed good practice in this area over a subjective data can usefully feed into the wider
number of years. Try contacting the local govern- picture.
ment in your area for information on this type of You might want to consider undertaking some
work, such as Citizens’ Panels, which are repre- first-hand research but first think about how much
sentative samples of residents who give their views time and money it will take. Will the results justify
on local services, priorities and plans (for an the costs? If you still think it is worth doing, who
example of the work of Citizens’ Panels see Bristol could do it? If it is very small scale you could
City Council website (http://www.bristol.gov.uk) perhaps undertake it yourself, maybe in collabora-
or perhaps look at your own local council website). tion with some colleagues.
There is more about research methods for finding out

people’s views in Chapter 7, section on doing your own
Local Media
small-scale research.
The opinions and data collected from local media
There are several methods of obtaining the views will provide you with a picture at a particular point
of the public at large, from informal discussions/ in time. Monitoring local radio, TV and newspapers
interviews to large-scale surveys using question- will give a view of any major changes in the com-
naires or in-depth interview techniques. Identifying munity. All this adds to the profile of needs you are
priority groups and thinking clearly about them building up, providing a basis for planning health
will influence the choice of methods used to contact promotion.
and involve them.
It is best to start with the characteristics of
the groups and then design the best approach. For
instance, how large are the relevant groups? Do Assessing Health
they have particular age, class or ethnic structures? Promotion Needs
What makes it a group (geography, membership,
current use of services and facilities)? Are the The assessment of health promotion needs can be
members of the group mobile? Do they have easy approached systematically by asking a series of key
access to transport? What times of day are they questions. The answers will help you to decide
likely to be available for meetings? Be absolutely whether you should respond to a particular need,
clear about what sort of relationship you are pro- and if so, how.
1. What TYPE of Need Is It? that this applies in most localities with poor public
transport. So, collect information only if the answer
Is this a normative, felt, expressed or comparative to a question is really not known. Have the views
need? of the clients been sought? Do they see this as
In a sex education class in a school, for example, a need?
what kind of need is being met: the normative
needs decided by the school nurse; the personal,
social and health education (PSHE) teaching team 4. What are the Aims and the
and the school governors; or the felt or expressed Appropriate Response to the Need?
needs of the school pupils; or the comparative See the section on setting aims and objectives in
needs decided after looking at what was being Chapter 5 for a more detailed look at setting aims and
made available on the PSHE curriculum in other objectives and identifying appropriate ways of achieving
schools; or what the comparative need for particu- them.
lar types of sexual health education, such as high
teenage pregnancy rates, in a local area are com- Health promotion cannot solve all problems or
pared to national figures suggesting a need for meet all health needs. You should be clear on what
more work on contraception advise? the need is, then what your aims are for meeting
that need, then the appropriate way to meet it. For
example, there may be an identified normative
2. Who Decided That There Is a Need? need to increase the uptake of immunisation and
Whose decision is it: the health promoter’s, the aim to achieve an 80% uptake rate. You then have
individual or group, or both? to decide the appropriate way to achieve your aim.
Sometimes the answer to this question is not It would be all too easy in this case to say that there
immediately obvious, because the need has emerged is a need for a health education campaign to get
after discussion between the health promoter and parents to have their children immunised because
their clients. People do not always know what they messages about attending immunisation clinics
need or want, because their awareness and know may be seen to be the answer. But this may make
ledge of the possibilities are limited. The health no difference because the appropriate response is to
promoter may help by raising awareness and educate the health professionals who are being too
knowledge of health issues; in this way she may cautious and withholding immunisation wrongly
create a demand (an expressed need) for health when a child has only a mild contraindication, or
promotion. For example, the public’s demand for to move the time and/or location of the clinics so
nonsmoking in restaurants came only after health that working parents, and those without cars, are
promoters had raised awareness of the hazards of able to bring their children.
passive smoking, which motivated people to Case studies 6.1 and 6.2 offer examples of how
express their need for a smoke-free environment in need for health promotion is assessed, applying the
eateries. An ideal situation is when there is a synergy four assessment questions. Exercise 6.3 asks you to
between clients’ and health promoters’ needs. think about assessing a need in your own area
of work.
3. What are the Grounds for

Deciding That There Is a Need?
Setting Health
Is there any evidence of need in the form of objec- Promotion Priorities
tive data, such as facts and figures? If local data are
not available, has the information been collected in You may have a large number of health promotion
other localities and is it reasonable to assume that needs that you feel should be met, but there are
the same conditions will apply? Be aware that always constraints on resources, such as time and
gathering data can be a delaying tactic to avoid finance. Concentrating effort on priority areas is
doing something about an obvious problem. For essential to ensure quality and effectiveness.
example, surveys have shown that elderly people Before attempting to set priorities it is helpful to
without cars find it difficult to get to hospitals if analyse current practice and recognise the wide
public transport is poor. It is reasonable to assume range of criteria that will affect decisions about
CASE STUDY 6.1 IMPROVING UPTAKE OF TB SCREENING SERVICES

Background in a community. Prior to this scheme there was a lack
TB incidence has varied over the years across of any form of recruitment into screening other than
north-east central London, and in Camden is relatively through port health and GP/hospital appointments.
high compared to other PCT areas. Targeted work was
required with the community to improve uptake and 4. What are the aims and the appropriate response
information about TB screening services. to the need?
The project aims were to encourage individuals from
1. What sort of need is it? new migrant communities to engage with health
The need to increase community knowledge and screening services available in the borough, with a
uptake of TB screening services was both normative particular focus on TB.
(based on policy directives and professional opinion) NHS Camden is now implementing the following
and comparative (based on activities in other PCT interventions, based on the primary research results:
regions). ■ TB posters, leaflets and information cards.
■ Welcome pack for new migrant or those new to
2. Who decided that there was a need? health services in Camden.
The local public health specialists and practitioners ■ Stakeholder toolkit.
acting on national policy directives decided there was ■ Stakeholder training around screening pathways in
a need for this initiative. the borough and target audience insights.
■ Peer-to-peer activity.
3. What are the grounds for deciding there In addition to this, stakeholders identified that
is a need? sustained outreach work and more peer-to-peer
The grounds for deciding there is a need was based education was needed in relation to accessing
on the above average TB incident rate per 100 000 in screening services within the borough. It was also
Camden and the existence of national policy stating thought that there needed to be deeper engagement
TB information should be available for all newcomers work with Somali, Bengali and homeless groups.
(Case study prepared by Aideen Dunne, Health Promotion Specialist, NHS Camden.)
priority, but it is important to consider whether

EXERCISE 6.3 Assessing a health promotion need
focusing all health promotion effort on those most
Use the following questions to assess a health at risk will, in the end, be of greatest benefit.
promotion need that you have identified in your own When reducing the incidence of coronary heart
work, or one which you are likely to meet in the disease, for example, two broad approaches
future. can be used: the high-risk and the whole population
1. What type of need is it? approaches. The high-risk approach identifies
2. Who decided that there is a need? people particularly at risk, such as smokers, people
3. What are the grounds for deciding that there is who are obese or who have high blood pressure,
a need? and develops interventions with these people to
4. What are the aims and appropriate response to change lifestyle factors and treat their raised blood
the need? pressure, for example. But there may be poor return
for effort, as these groups could include addictive
smokers with poor diets who have no intention of
changing, or people so overwhelmed with social
health promotion interventions. Undertaking Exer- and/or psychological issues in their lives that
cise 6.5 enables you to focus on these factors. tackling smoking and eating habits is the last thing
The need to prioritise is vital, but one difficult on their minds even if they would like to make
issue to consider is how to approach work with changes.
people whose health experience is poor. It is auto- The whole population approach works at
matic to consider that these people should be top community rather than individual level, with, for
CASE STUDY 6.2 A PHYSICAL ACTIVITY SCHEME TO IMPROVE ACTIVITY LEVELS IN LOW INCOME
HOUsEHOLDS
Background 3. What are the grounds for deciding there
In 2008 Pro-Active Camden commissioned a Physical is a need?
Activity Needs Analysis which surveyed Camden Analysis of the community survey, consultation with
residents. This survey had a particular focus in the local leisure providers and comparison of local health
four priority wards of Camden, which has the highest statistics provided the rationale for targeting this
rates of all-cause mortality. The findings showed that need with the methods employed.
insufficient time and cost were the two main reasons
for not participating in physical activity. When asked 4. What are the aims and the appropriate response
where they would most like to undertake physical to the need?
activity, the majority of residents stated a leisure/ The aim of this project was to increase access to
sports centre. Camden has a number of gyms spread physical activity among Camden’s low-income
out across the borough that can provide access to population by offering free access to specific leisure
swimming, gym equipment and fitness classes in one centres situated across the borough. All Camden
location. residents who qualified (in receipt of a specific set of
benefits) received free access to a local leisure centre
1. What sort of need is it? for a month. Those who attended five or more times
The need for low-cost physical activity is an expressed during that month then qualified for 6 months funded
need by Camden residents. membership. This strategy removed cost as a barrier
Low physical activity levels and the need for but participants paid through effort by attending five
physical activity intervention is a comparative need as or more times.
the target group for this scheme had lower activity A marketing strategy to raise awareness of the
levels than the general Camden population. The scheme was put in place: this included a direct mail
leisure providers also felt that low cost was a need. to Camden residents registered as unemployed or in
receipt of certain benefits, advertisement in local
2. Who decided that there is a need? newspapers and media packs mailed to community
The public health team at NHS Camden made the amenities (including post offices, job centres, housing
decision to explore barriers to physical activity based offices and healthy living centres).
on national policy directives to increase physical
activity levels; however the scheme was in response
to an expressed community need.
(Case study prepared by Aideen Dunne, Health Promotion Specialist, NHS Camden and Nick Pahl, Public Health Strategist, Screening,
NHS Camden.)
example, strategies to improve access to cheap complement each other. This is why developing
healthy food, increase skills and confidence in pro- partnership working is so important as it allows
ducing healthy meals for families, and community different aspects of the same issue to be addressed
development approaches to build up social support. by the health promoters who are best placed to
At the same time, supporting changes at a wider tackle a particular aspect at a particular time, thus
population level, such as reducing the underage achieving greater impact.
sales of cigarettes, and lobbying for increased There can be no exact method for setting priori-
income support, could result in better health gain ties because they ultimately depend upon the nor-
across whole populations. mative judgements and the available resources of
Generally, both approaches need to be taken (not the health promoters involved. But it may be helpful
necessarily by the same health promoters), as they to work through the checklist in Exercise 6.4.
EXERCISE 6.4 Setting priorities for health promotion

1. Health promotion issues, approaches and you know whether there is evidence that work
activities focusing on specific issues will be successful?
Would you get more health gain for your effort if
Do you define your priorities in terms of:
you focused on whole populations rather than those
■ Issues that have an influence on health (the wider most in need?
determinants such as poverty, unemployment,
5. Effectiveness
racism, ageism, inequalities)?
■ Health promotion approaches (such as medical, ■ Have you any evidence that health promotion in
behaviour change, social marketing, educational, your priority areas is likely to be effective?
client centred, societal/environmental change)?
See Chapter 7 for information on how to collect evidence.
■ Health promotion activities (preventive health
services, community-based work, organisational ■ Haveyou any evidence that it will provide value for
development, economic and regulatory activities, money?
environmental measures, health education ■ How could such evidence be collected?
programmes, healthy public policies)?
■ Health problems (such as heart disease, food
6. Feasibility
poisoning, cancers, HIV/AIDS, obesity, mental ■ Is it feasible for you to spend time with your
illness)? priority groups?
■ Do you have access to these groups?
Why?
■ Do you have credibility with these groups?
2. Consumer groups ■ Do you have the skills and resources to work with
Who are the people your health promotion is aimed at? these groups?
■ Policy makers and planners? 7. Working with others

■ Individual clients or service users? ■ Do you know what work is already being done with
■ Families? your priority groups, by other health promoters,
■ Selected target groups? community groups and voluntary organisations?
■ The whole community? If so, how do you define ■ Are you sure that your work will complement any
your community? other work that is going on and not be seen as
Why? duplication or interference?
■ Does your work fit in with existing local strategies
3. Age groups and plans for health promotion?
Do you define your priority consumer groups further in ■ Are there any local partnership groups already set
terms of age: children, young people, parents, older up to address the needs of your priority group?
people, etc.? 8. Ethics
Why?
■ Are there ethical aspects to your work which you
4. At-risk groups need to consider?
■ Do you define your priority consumer groups further ■ Is your work ethically acceptable to you?
in terms of high-risk categories such as smokers, ■ Will it be acceptable to your consumer groups?
people with high blood pressure, the unemployed or ■ Will it be congruent with their values?
those living on low incomes? If so, why? Have you ■ How may the desired outcome affect their lives?
examined the evidence leading to the identification
9. Add anything else you feel it is important
of these at-risk groups?
to consider
■ If your group includes people with highest health
needs, for example people living in areas of social Now identify your top priority and add any other
deprivation with many health and social needs, do priorities.
EXERCISE 6.5 Analysing the reasons for health promotion priorities

Identify a health promotion activity which has a high  I feel that it’s important.
priority in your work. This could be work that you  It is the established policy of senior managers.
undertake with a number of clients (such as a smoking  We have always done it and see no reason to
cessation programme) or just one (for example, a health change.
visitor talking to a mother about maintaining  There was pressure from the public.
breastfeeding); it could be part of your usual work or a  It was in response to a crisis.
special event such as a campaign. It will be especially  We had to be seen to be doing something.
helpful for the purposes of this exercise if you can  There is new evidence of need.
identify an area of work that has recently become a  There is evidence that the work has been
priority. effective in a similar area.
Now work through the following tasks.  It was the current national/local theme (e.g.
1. Identify who it was who decided that this work World AIDS Day).
should take priority (e.g. you? your seniors? your  We had a new staff member with special
clients? all three?). expertise, which we wanted to use.
2. List all the possible reasons why this work  We had to economise and be more efficient.
has priority – include the reasons that you  It was politically expedient.
are sure about as well as any that are  There was a change in national policy.
speculation. 3. Identify what you think the most important reasons
Your reasons could include any of the following and are. Do you think that they are sound reasons for
probably many more: setting priorities?
PRACTICE POINTS need? What is the evidence for deciding that there
is a need? What is the appropriate response to
■ You will have some scope for making choices about the need?
the range of health promotion activities you ■ Like all health promoters, you have a duty to
undertake. These choices must be based on a careful reassess priorities regularly, through analysing
assessment of health promotion needs. The starting whether your activities are targeted effectively, are
point is to undertake a needs identification process. feasible, complement the work of other practitioners
■ The views of users and receivers of services are
and are acceptable to local people.
paramount, therefore developing skills in gathering ■ Priorities depend ultimately on the normative
information directly from them is especially judgments of those involved. Best practice involves
important. in-depth discussion on priority setting with other
■ You can assess health promotion needs
health promotion practitioners and local people.
systematically by asking four key questions: What
kind of need is it? Who decided that there was a
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91
Chapter 7
Evidence and research in
health promotion
Summary
Chapter Contents
This chapter covers particular aspects of knowledge
National public health strategies 93 and skills that enable you to draw on evidence,
undertake research and use various techniques to
Local health strategies and initiatives 94
inform and prioritise your health promotion work.
Evidence-based health promotion 95 These include linking your work into broader national
and local health promotion plans and strategies,
Using published research 96
basing your work on evidence of effectiveness, using
Doing your own small-scale research 98 published research, doing your own small-scale
research, getting value for money, audit and health
Value for money 101
impact assessment.
Audit 102
Health impact assessment 103
The role of the NHS and local government in planning
health strategies is outlined in Chapter 4. How local
policy is made and implemented is discussed in
Chapter 16.
International (such as the World Health Organi-

zation (WHO) 2006) and national health strategies
focus efforts on agreed priorities, and provide the
framework for setting objectives and monitoring
progress towards their achievement. A health pro-
moter at a local level contributes to these broader
strategies and complements work of other health
promoters. Fig. 7.1 illustrates how health promoters
from different local agencies complement each
other’s efforts in contributing to national goals of
increasing physical activity in the population.
The role of the WHO and other international bodies is
discussed in Chapters 1, 4 and 16.
National Priority: National Priority:

Heart Disease and Stroke Accident Prevention
Reduce the risk of developing Help prevent falls by
heart disease and stroke. improving muscular strength
Lower blood pressure, reduce and flexibility in older people.
overweight and obesity Help prevent osteoporosis
National Priority:
National priority:
Mental Health
Cancer
Improve mental and social
Help protect against
wellbeing: help anxiety
cancer of the colon
and depression, improve
relaxation, provide social
interaction
INCREASE PHYSICAL ACTIVITY
Transport and Educational settings: NHS: encourage patients

environmental set patterns of to be more active as part
planning: enjoyable physical of their everyday life; give
promote walking activity in childhood advice and suggestions
and cycling in a and open school about where to go, what
clean, pleasant facilities to local to do; link with local
environment community recreational and sports
facilities to encourage use
by NHS staff
Recreational and Research establishments, Employers:

sports settings: universities: undertake provide secure bike
encourage people to research and evaluation storage, bikes on loan,
try out a range of local programmes showers, and good
of fun activities; to identify effective cycling mileage rates
adopt opening times approaches to promoting in order to encourage
and prices which physical activity employees to walk or
enable low income cycle to get to work
and disadvantaged and for journeys during
groups to use facilities working hours
Fig. 7.1 Contributing to priorities in national strategies. Local complementary contributions to promoting physical
activity. Heart disease and stroke, accidents, cancer and mental health feature as priorities in national strategies for health
in England, Scotland, Wales and Northern Ireland.
Chapter 7 Evidence and research in health promotion 93
● England: Saving Lives: Our Healthier Nation

National Public Health Strategies
(DoH 1999) and Choosing Health: Making Healthy
The first national health improvement strategy in Choices Easier (DoH 2004). The key principle of
England was The Health of the Nation (Department Choosing Health: Making Healthy Choices Easier is
of Health (DoH) 1992). There were comparable to support the public in making healthier and
strategies for Wales, Scotland and Northern Ireland. more informed choices in regards to their
health. The Government pledged to provide
See also Chapter 1, section on national initiatives. information and practical support to get people
The National Audit Office (1996) reporting on motivated and improve emotional wellbeing
The Health of the Nation targets concluded that, while and access to services so that healthy choices
the initiative was making an impact, progress was are easier to make.
uneven and slow. Deaths from heart disease, strokes ● Northern Ireland: Health and Wellbeing: Into the
and certain cancers were being reduced but there Next Millennium (Department of Health and
were rising levels of obesity, alcohol consumption Social Services (DHSS) 1997), Investing for
by women and smoking by children which threat- Health (Department of Health, Social Services
ened to undermine health gains. and Public Safety 2002). Investing for Health
In the areas where targets were being reached, it presents a cross-departmental, multisectoral
was difficult to determine how far this was due to framework for action to improve health and
health promotion efforts (Appleby 1997). For wellbeing. The strategy recognises the
example, there was a decrease in the rate of acci- important contribution to be made by members
dental deaths (many due to road accidents) in chil- of statutory and nonstatutory groups,
dren. But this could have been because of improved community and voluntary groups. The
education about accident prevention or a safer envi- principles and values that should guide the
ronment, such as more traffic calming schemes. Or improvement of health are identified and the
it could have been because more injured children costs of poor health are highlighted. The aims
were saved from dying with better or quicker treat- are to address a broad range of economic, social
ment, or maybe even because parents were informed and environmental determinants of health and
of the risks of letting their children out to play, walk wellbeing.
to school or cycle on the roads, so that their expo-
● Scotland: Towards a Healthier Scotland (Scottish
sure to life-threatening risks was reduced.
A final assessment of The Health of the Nation Office (SO) 1999). Better Health, Better Care:
(DoH 1998) concluded that, although the strategy Action Plan (SO 2007). Better Health, Better Care
was widely welcomed, it did not realise its full has central themes of patient participation,
potential and was not seen to be as important as improved healthcare access, and improving
other health service priorities, such as waiting lists. health and tackling health inequalities. This
Some key findings were that the strategy made little action plan sets out to help people to take more
impact on local policy making, caused only a slight control of their health, especially in
increase in health promotion spending, did not disadvantaged communities, ensuring better,
impact on primary care practitioners or hospital local and faster access to health care. The three
services, and was generally disliked by local author- main components of health improvement,
ities because of its disease-led targets. On the posi- tackling health inequality and improving the
tive side, the evaluation indicated that the strategy quality of health care are set within a
enabled coordinated health promotion efforts, pro- comprehensive programme of targeted action.
viding a focus for organisations outside the NHS to ● Wales: Promoting Health and Wellbeing:
be involved and a spur to multiagency action where Implementing the National Health Promotion
previous joint work had not existed. Strategy (National Assembly for Wales (NAW)
The report made useful recommendations for the 2001a) and the associated Improving Health in
success of future health promotion strategies, Wales: a Plan for the NHS and it’s Partners (NAW
calling for more evidence-based practice and evalu- 2001b). Promoting Health and Wellbeing:
ation and performance management. Implementing the National Health Promotion
New national strategies were introduced in the Strategy sets out key elements of helping
late 1990s and then again in the 21st century: communities through local health alliances,
health promoting schools, community health for LSPs and http://www.idea.gov.uk for informa-
development, reaching young adults and tion on local area agreements and LSPs).
developing a healthy workforce. There are
targeted programmes covering a wide range of
Community strategies
public health action. Other elements of the plan
cover improving the skills and knowledge of Local authorities have powers to promote or
health promoters, better communication of improve local economic, social and environmental
health information, health impact assessment, wellbeing. They are required to prepare community
and research and evaluation. strategies (or plans) and to coordinate these activi-
Health promoters need to take account of these ties (see Darlow et al 2008) and associated partner-
strategies and their emphasis on individual respon- ships across a wide range of agencies (see, for
sibility for health, the need to address the wider example, LutonForum 2005).
determinants and the importance of partnership
working. Neighbourhood renewal strategy
See Chapter 1, section on national initiatives, for more The Neighbourhood Renewal Strategy and Fund
about inequalities targets. was launched in 2001 (Social Exclusion Unit 2001)
and set out a joined-up approach to tackling the
social and economic determinants of health in the
most deprived local authority areas.
Local Health Strategies
and Initiatives
Healthy living centres
There are many government-initiated local health The Healthy Living Centres (HLCs) Initiative was
programmes that provide sources of funding for launched in 1999, funded from the National Lottery
health promotion. Local strategies were given new to develop a network of HLCs across the UK. This
impetus with the development of health improve- funding is usually used for programmes of activity
ment programmes, later known as health improve- rather than a physical building. For examples of the
ment and modernisation plans (HIMPs). These work of HLCs see Rankin et al (2006) and for an
required more coordination between local agencies evaluation of the whole scheme see Hills et al
at both a strategic and operational level than had (2005). HLCs are not mentioned in recent policy, but
previously been the case. HIMPs for action were the intention at the outset was that HLCs would
based on local needs that cover prevention and become sustainable and there is evidence that
health promotion as well as treatment and care this is happening (see, for example, Chesterfield
services. They emphasised reducing inequalities Borough Council 2009).
and developing partnerships to address locally
identified needs and national health strategy priori-
ties. To explore the impact they had on health pro- Health action zones
motion see Abbott & Gillam (2001).
The first wave of health action zones (HAZs) was
See also Chapter 4 for the role of the health service and set up in 1997 with special government funding
local government in promoting health. to improve health outcomes and reduce health
inequalities (Health Development Agency 2004).
Others local strategies include the following.
HAZs have pioneered new ways of tackling health
inequalities through partnership working between
the NHS, local authorities, community groups, the
Local strategic partnerships voluntary and private sectors; linking health, regen-
At a local level the NHS is involved in local strate- eration, education, housing and anti-poverty initia-
gic partnerships (LSPs), has oversight of the tives. A central aim for HAZs was integrating the
community plan (see below) and in areas of depri- services and approaches they develop into main-
vation is responsible for developing a local strategy stream activity, and some made considerable
for neighbourhood renewal (see http://www. progress and had an impact on local health improve-
neighbourhood.gov.uk for links to local websites ment (Barnes et al 2005, Bauld and MacKenzie
2007). Where HAZs still exist they have been incor-

EXERCISE 7.1 Finding out about national and
porated into mainstream agencies, for example, local health promotion strategies
Northern Neighbourhoods Health Action Zone
(http://www.nnhaz.co.uk). 1. Have a look at the national strategy for health in
your country (see section on National Health
Strategies above to find out about yours). Try the
The New Deal for Communities (NDC) Internet, libraries at educational institutions or at
work, colleagues in health promotion or planning
The NDC programme involved funding to poorest at your place of work, or contact the public health
neighbourhoods in the country for 10 years to department of your local NHS organisation.
support plans that bring together local people, com- 2. What do you think are the good and not-so-good
munity and voluntary organisations, public agen- points about your national strategy?
cies and local business in an attempt to make lasting 3. How does your own health promotion work
improvements to health, employment, education contribute to the aims set out in the national
and the physical environment. It was the intention strategy?
that these improvements would be delivered in a 4. If you work in the NHS or local authority, list your
way that could be sustained beyond government local health plans and strategies and assess:
funding and into the long term. The government  What are the good and not-so-good points
has issued various guidance notes which relate to about your local plans?
succession, but Healey (2009) argues that it is too  How do the local plans relate to your national
early to make an assessment of the contribution that strategy?
guidance and shared good practice from the NDC  How does your own health promotion work
programme is making to the development of local contribute to the aims set out in your local
sustainability plans in NDC areas. For an example plans?
of how NDCs function see Newcastle New Deal for
Communities (http://www.newcastlendc.co.uk).
● Knowledge of the hierarchy of evidence.

Sure Start
● Assessment of evidence of effectiveness of
This is a government scheme which aims to support services, programmes and interventions, which
parents and children under 4 years in areas of high impact on health.
health need (see Gidley 2007 for a more detailed ● Conducting a literature review, which includes
discussion of the Sure Start programme and http:// the use of electronic databases, defining a
www.dcsf.gov.uk for publications relating to recent search strategy and summarizing results.
Sure Start funding and other initiatives).
● Applying research evidence, evidence of
Exercise 7.1 aims to help you find out about
effectiveness, outcome measures, evaluation
national and local health strategies relevant to your
and audit to influence health promotion
work.
programme interventions, services or
development of practice guidelines.
● Interpreting and balancing evidence of
Evidence-Based Health Promotion effectiveness from a range of sources to inform
decision making.
Delivering evidence-based health promotion is a
key goal within the international, national and local See Chapter 2 for more information on competencies in
strategies outlined above (Jones & Scriven 2005, health promotion.
Scriven 2008) Health promoters are required to An evidence-based approach provides a defense
know how to assess the evidence and apply the against the indiscriminate use of practices in situa-
assessment to practice. tions which have no research-based legitimacy.
This requires competencies in: Evidence-based health promotion requires a culture
● Critically appraising primary and secondary where you openly share your experience and write
research. up and publish your work, which enables others to
learn from your successes and failures. It uses the circumstances in which you are working may be
skills of reflective practice, thinking about what you unique. So the best that can be done is to be aware
do and questioning whether it is the right approach of what the published research in related areas of
in your situation. work tells you, and to reflect on how what was
learned might apply to your circumstances. Where
evidence is not available, it is vital to ensure that
How Do You Know What Works?
you evaluate your work in order to add to the evi-
There can be a gap between evidence and practice. dence base by drawing the evidence from your
It is not always easy for practitioners to keep up-to- practice and disseminating the results.
date with new research findings, or to apply research It also helps to think carefully about what consti-
findings in their own particular situation. Attention tutes evidence (for a useful discussion on these issues
needs to be given to how research findings can see Kelly et al 2004). Evidence can be drawn infor-
best influence and also emerge from practice, and mally, with the views of local people and your own
the processes of disseminating and implementing experience also constituting evidence. Your job as a
health promotion research. health promoter is to use your judgement to decide
There are many published research studies that whether the evidence available applies to your
help to show which health promotion interventions clients and circumstances and, if so, how. GPs, for
work best. These are easily accessible on the example, may quote a number of factors which they
Internet at such sites as Cochrane (http://www. believe provide evidence that health promotion is
cochrane.org); the International Union of Health effective, including changes in the health or health
Promotion and Health Education (IUHPE) data behaviour of their patients over time.
source (http://www.hp-source.net) and the main However, formal sources of evidence are gener-
evidence-based Internet site for health promotion in ally regarded as the most reliable, so you should
England, the National Institute for Health and Clin- plan carefully and evaluate or audit what you do.
ical Evidence (NICE) (http://www.nice.org.uk). In this way you will be building up your own body
Health promotion is complex and it is sometimes of knowledge about what is effective.
difficult to provide evidence of effectiveness for
Audit is discussed later in this chapter.
single interventions. Often it is not one intervention
that produces results, but a combination of activi- Finally, it is also important to bear in mind that
ties, of which you may be involved in just one, as your decision about whether to do a particular
Fig. 7.1 demonstrates. Another example is prevent- piece of health promotion work should also be
ing childhood obesity, where the evidence is that a based on ethical considerations. You could decide
multifaceted approach is the most effective. A com- that it is your responsibility to intervene, even
bination of interventions range from targeting ante- though you have little or no information about
natal education, to working with parents and what might work. Health promotion is driven by
ensuring they have access to buying affordable both values and evidence, which are often inter-
healthy foods, to increasing children’s physical twined. So there are two key questions: Do we think
activity levels, through the targets set by the Schools this ought to be done? and Will it work?
Sports Strategy (OFSTED 2006) and ensuring
See Chapter 3 for more about values and ethics in
healthy food consumption while children are at
health promotion.
school using the new standards, which cover all
food sold or served in schools (Department for
Children, Schools and Families 2005). Using Published Research
Research shows that for many health promotion
issues a more comprehensive, integrated approach Health promoters need to be well informed about
that focuses both on attitudes and behaviours and published research and also how to use their know
changes to such things as the environment and leg- ledge of research findings to improve their practice.
islative and fiscal policies is the most effective (see, Familiarity with research findings can also give you
for example, National Audit Office et al 2006). arguments on which to base a case for more, or dif-
Evidence may also not exist. The particular piece ferent and better, health promotion. Keeping abreast
of work you plan to undertake may not have been of current evidence should be part of your everyday
done before, and indeed the particular set of working practice.
How to Search the Literature ● edition, if not the first

● chapter, or numbers of pages, if you are only
You may sometimes wish to find out about research
going to refer to part of the book
on a particular topic, perhaps because you are pro-
● place of publication
posing to introduce new health promotion work
and want to know what has been shown to work ● publisher.
best. For example, imagine you are a nurse working For articles in journals you need to record:
in cancer care and you are considering introducing
a counselling service for women who are undergo- ● author’s surname and initials
ing mastectomy (surgery to remove a breast, usually ● year of publication
because of breast cancer). You want to know if ● title and subtitles of article
research shows what the health promotion needs of ● journal title
these women are and how best to meet them. Where
● volume and part numbers
do you start?
● the inclusive page numbers of the article
First you need to establish a research question. It
pays to take time to discuss this with colleagues and ● date of publication.
you could also discuss it with someone who has If you are gathering research evidence that will be
recently had a mastectomy. What did she find used to inform a health promotion decision or
helpful, and what was unhelpful? action, then the first thing you need to know when
Once you are clear about what you want to find reading an article is whether it is a report of actual
out, list no more than six key words that feature in research or just a knowledgeable account of facts
your question. The cancer care nurse might include and opinions. The abstract, the summary paragraph
the words mastectomy, needs and counselling in at the start of an article, will quickly inform you
her list. Then write words that mean the same thing, why a study was done and the main findings.
or are similar in meaning, by each key word. For Research reports usually have the following format:
example, you might put breast removal as an alter-
native to mastectomy, and advice as an alternative ● Introduction – background to the study.
to counselling. These key words and their syno- ● Literature review – critical summary of
nyms/alternatives will be helpful when you go to previous and related research.
the library or search on the Internet (for excellent ● Method – a description of how the study was
guides to doing your literature search and finding carried out.
information online, see Aveyard (2007) and Dochar- ● Results – the findings of the study.
taigh (2007)). In addition, many journal articles
● Discussion – a discussion of the findings.
include a list of key words after the title, which will
● Conclusions – the implications of the findings.
help you to know whether the article is likely to be
of interest to you. When you have found a few refer- ● References – all the studies and books referred
ences, you can start by reading the most recent one. to in the article.
This will provide you with more references. Once You need to read research articles critically, using
you are under way, the next problem is to avoid the following questions:
being swamped by information. Here again, your When was the research carried out? Although the
key words should be useful in stopping you from article is recent, it could be reporting on research
being side-tracked and in keeping your research that was carried out some years previously and has
question in mind. been superseded by more up-to-date research.
It is important to keep records of what you Why was the research undertaken? Do you see the
read. There is computer software designed to help need for this research? Will it contribute new know
you store and retrieve references (see for a compari- ledge on the subject? Will this knowledge be useful
son of the different software http://en.wikipedia. in practice?
org). For a book, you need to record: How was the research carried out? Did it use
methods and tools that were likely to provide
● author’s (or editor’s) surname and initials answers to the questions posed by the researchers?
● year published What type of research was carried out? For example,
● title and subtitle if the researchers wanted to find out what works in
changing the behaviour of sedentary people with whether and how they apply to your work, in
angina to cause them to take more exercise, then certain situations you may wish to carry out research
experimental research would be required. This is yourself. For example, you and a group of col-
research that establishes a relationship between leagues may have uncovered an unmet health pro-
cause and effect, often through studying subgroups motion need and your manager has agreed to fund
of people, where the experimental subgroup experi- a study to look in more detail at the need and how
ences the intervention under consideration, and the it could best be met.
control subgroup does not. Another type of research What is defined as research here is a planned,
is action research. This is used to find out exactly how systematic gathering of information for the purpose
to implement changes, or solve problems, in a spe- of increasing the total body of knowledge. If you
cific situation through watching and documenting are inexperienced, it is important for you to read
in a systematic manner how the changes are intro- extensively and try to elicit help from an experi-
duced. (See Bowling (2009) for an excellent and enced researcher. The following information
detailed overview of research methods and meth- should help to guide you in your reading and also
odological considerations.) introduce you to the process of undertaking small-
Does the researcher draw reasonable conclusions from scale research.
the results? This can be a difficult question to answer, The research process involves carrying out some
especially if, for example, it is quantitative research specific tasks, which are set out in Box 7.1. Although
and you are unfamiliar with statistics. If you are not the tasks will tend to be carried out in the sequence
sure that you understand, it is important that you set out in the box, this is not always the case, for
read more on critiquing research, particularly if you example, you may write parts of the research report
are going to be implementing the findings. (See incrementally, as you go through each research
Caughlan et al 2007 and Ryan et al 2007 for more task. You may have a much clearer idea about the
detail on critiquing research articles.) purpose of the research after you have read the
How could or should this research affect health promo- literature on other investigations in your area of
tion practice or policy? Even if the research was not interest.
carried out in your specialty or particular area of The most important task in this list is the first
work, it could have implications for them. For one, as the kind of question you want to answer will
example, findings about how best to communicate form the basis of the whole project. For example,
with patients who are very anxious after a heart suppose you set the question ‘What is the best way
attack could be used to help improve communica- to encourage a group of university undergraduate
tion with patients who have cancer. students to engage in safer sex practices and to use
Through asking these, and other, questions you condoms?’ This question is concerned with ways of
should be able to come to a judgement about motivating and perhaps changing attitudes in order
whether a piece of research is reliable. It should to encourage health-enhancing behaviour. The
have: experts in this field are psychologists, so it is to the
● been carried out by competent researchers body of psychological research literature that you
● used appropriate research design
will turn to for soundly based principles. However,
● contained sound baseline data
● used a research instrument (such as a
questionnaire) that has been piloted (tried and BOX 7.1 Research tasks
tested first to identify and correct any
1. Define the purpose of the research.
problems) and validated (tested to show that it
2. Review the literature.
really does measure what it was supposed to
3. Plan the study and the method(s) of investigation.
measure).
4. Test the method by carrying out a pilot study.
5. Collect the information.
Doing Your Own Small-Scale 6. Analyse the information.
Research 7. Draw conclusions based on the findings of the
analysis.
While you can improve your effectiveness through 8. Compile the research report.
examining research findings and considering
you may instead be concerned to know which of a Questionnaires

number of alternative effective ways to motivate
students to use more condoms is best value for These are useful when you want to collect informa-
money. If so, you will want to look at cost-effective- tion from relatively large numbers of people. Ques-
ness studies and make use of the work of health tionnaires should be kept as simple as possible, but
economists. It is vital that you are clear about the this does not mean that they are easy to design. A
practical reasons for engaging in this research. If great deal of care is needed in the formulation of
you are very sure about why you are doing it, who questions to ensure that valid conclusions can be
will use the findings and for what purposes, then drawn from the answers. Questionnaires are most
you are likely to come up with some useful answers. useful for collecting information that is quantifia-
If you are distracted by interesting but irrelevant ble, such as factual knowledge. Advantages of
information, your research could be confused and questionnaires include: they can be answered
therefore flawed. anonymously, and respondents may therefore be
Time spent on task 3, planning, is a good invest- more truthful, and they can be given to a whole
ment. If you are going to apply for funding, your group of people at the same time, so using respond-
planning must include investigating sources of ents’ and researcher’s time effectively.
funding and the particular interests of different The questionnaire should always first be piloted
potential funders. Many tasks can take longer than on a small sample of people from the group for
the initial estimate and you will need to allow which it is intended. You will then be able to iden-
plenty of time for consulting people; for example, tify and redesign any questions that have been
to arrange interviews if this is part of the research. misinterpreted.
Ethical issues and the need to apply for permission The response rate to questionnaires can be low,
from ethical committees if you are using human and you may need to think about the implications
subjects must also be taken in to account. Ethics of this; for example, will the results really reflect the
committees in the NHS will evaluate the research views of the target population? Also, some people
proposal and will require additional information may not want to complete the questionnaire and
about issues such as confidentiality (for a useful even if they fill one in they may do so casually,
discussion on the complexities of gaining ethical without giving it careful thought.
approval see Jamrozik 2004). You need to consider right from the start how the
You will also need to consider ways of collecting information collected will be analysed. Decisions
the information you need. Any information col- about whether computer software programmes,
lected needs to be valid and reliable. Validity means such as SPSS (see Pallant 2007), will be needed to
actually measuring what you purport to measure. analyse the information may affect the design of the
For example, if you are attempting to measure questionnaire. Consultation with a statistician and/
the success of health education in encouraging a or an experienced researcher may be helpful at this
group of people to take more physical exercise, point.
a valid measure would be directly to observe You have to put a lot of thought into the design
whether or not they spend more time on physical of quantitative questionnaires by clarifying closed
activities. Asking them to complete a written ques- questions with defined ways of responding (such as
tionnaire may not give valid responses because tick boxes), so that they will give accurate results.
research shows that people often respond to ques- Qualitative questionnaires with open questions can
tions and questionnaires in ways they think the be more complicated to analyse.
experts want them to. Reliability means that if the See Chapter 10, section on asking questions and getting
research is repeated using the same research instru- feedback, for more about open and closed questions.
ments, it will give the same results (for examples
of how to test reliability and validity see Elley
Personal interviews
et al 2003).
With face-to-face interviews you can develop
rapport and encourage people to talk more openly.
Basic Tools of Research
You may find out things that you did not think to
There are a number of basic tools used in health ask about, but which are very relevant. The main
promotion research. advantage of personal interviews is that there is
more scope for initiative by the interviewee. For researcher is also actively involved in what is being
example, the interviewee can seek clarification, and observed, such as actively contributing to discus-
may be able to express views and opinions more sions in a meeting. Non-participant observation means
easily verbally than in writing. The disadvantage is that the researcher takes no part in what is being
that, unless you are very skilled, you may bias the observed.
response, that is, you may get the responses you Advantages of participant observation are that
want to get or expect to get. For example, asking the researcher may be more aware of what is going
‘You do feel better, don’t you?’ biases the answer on, including less tangible things such as the mood
towards ‘Yes’, whereas ‘Do you feel better?’ removes of a group of people. However, the researcher could
some of this bias. have difficulty in making objective observations
Interviews can be one-to-one or with groups, and may find it difficult to record what is happen-
face-to-face or by telephone. They can be organised ing, so that information could be lost. The non
through using pre-prepared questions (a structured participant researcher may find it easier to make
interview) or allowed to flow more freely. At one objective observations, and may be able to plan and
extreme, you could design an interview schedule record observations more easily. On the other hand,
that looks like a questionnaire; at the other extreme, having an observer who does not participate can
you might simply have three or four broad head- seem threatening; people might not open up or may
ings which you wish to discuss (a semistructured not behave as they normally do. This could have a
interview). Box 7.2 is an example of a telephone big effect on what is observed, and invalidate the
interview schedule. Special interview groups, such research (see Cooper et al 2004 for an example of
as focus groups, concentrate on a particular issue the use of participant and nonparticipant observa-
through focusing on pre-determined questions (see tion in health research).
Saks & Allsop 2007 and Bowling 2009 for more
details on survey design, interviewing and con-
Sampling
ducting focus groups).
If it is too expensive or time-consuming to collect
information from the whole population or group
Participant and nonparticipant observation you are interested in, then you need to select indi-
Observation can include observing behaviour, such viduals so that you avoid getting a biased response.
as how well a person performs an exercise routine, There are a number of sampling techniques which
and physiological observations, such as monitoring can be used to ensure that the sample is representa-
weight. Participant observation happens when the tive of the whole population.
Random sampling. This involves identifying
people at random from the whole group. For
example, imagine you are a practice nurse. Using
BOX 7.2 Patient satisfaction with health the practice age–sex register you could decide at
education and information: telephone random on a number between 1 and 10 (say 5) and
survey schedule send out questionnaires to the 5th, 15th, 25th, 35th
■ When you were in hospital, what information (and so on) person on the list.
were you given about your illness? Quota sampling. This uses your knowledge of a
■ Do you now feel you have sufficient information particular group to help set criteria about who to
about what was wrong with you? include in the sample. Criteria you might use
■ Were you able to discuss your anxieties with include age, sex and ethnicity. Once the group has
anyone while you were in hospital? been divided into segments, using your criteria you
■ Who did you prefer to discuss things with? can use a proportion from each segment for your
Prompt: Was it a nurse, a doctor, another sample. This ensures that people with certain char-
professional or a domestic helper? acteristics are not over- or under-represented.
■ Did you have sufficient privacy to feel able to talk Convenience sampling. This means that researchers
openly? Prompt: Did you have access to a question the people they can get hold of at the time.
comfortable, private room for private This is biased but, accepting that it is very difficult
conversations? to avoid bias altogether, it is important to decide
whether the particular bias that has been
introduced is acceptable. Bias should be discussed of good quality. Poor research is worse than
in any dissemination of the research (see Bowling, no research because it wastes resources and
2005, 2009 for further details on sampling and misleads.
research bias).
The Research Report Value for Money

See also the section on report writing in Chapter 8, and
You need to think not only about evidence but also
the section on written communication in Chapter 10.
the question of whether you are getting value for
The final stage of your research will be to produce money. Health economics is a discipline that pro-
a written report, which will disseminate your find- vides a way of thinking about value for money and
ings. People who read the report may be interested making efficient use of scarce resources. It is not
in assessing the validity of the findings for them- about doing things more cheaply, but about choos-
selves, in repeating the research in similar circum- ing priorities and making the best choices with the
stances and avoiding any pitfalls, or in applying the resources available. The health economist focuses
research findings in the context of commissioning on costs and outcomes. Costs involve much more
or providing health promotion services. So the than money: they may include people, equipment,
report should be written with the objective of buildings and intangible costs, such as distress.
helping readers to use it in these ways. You may Outcomes include length of life and things that are
need to consider producing more than one version more difficult to measure, such as quality of life.
of the report for different groups of readers; for There are a number of national centres of excellence
example, a two-page summary for community in health economics which provide a wide range of
groups, and a full report for your health promotion useful resources, such as the one in York (http://
professional and managers. www.york.ac.uk).
The contents of your research report may include
the information set out in Box 7.3, although not
Opportunity cost
every point will be applicable to a particular report,
which should be written with the needs of the This is an important concept. Resources are finite
readers in mind. and prioritising one intervention or service means
Finally, a warning: in a field like health promo- giving up the potential benefits of another. So, for
tion, interpretation of research data is a complex example, money devoted to a drugs mass media
matter, often because of underlying differences of campaign takes money away from drug education
opinion on what is health and what constitutes in schools. All health promotion activities involve
success. It is therefore all too easy for the sceptical the use of resources that are expected to produce
to dismiss research findings. So it is extremely benefits, but at the same time incur opportunity
important that any health promotion research is costs in the form of benefits that will be forgone. It
BOX 7.3 Checklist of the contents of a research report

■ Abstract (concise summary of the research). A discussion of the ethical implications.
■ Background (statement about the purpose of the Data analysis methods and the reasons for selecting
research, the background, the reasons for carrying these methods.
out the research and the questions to be answered). A description of the pilot study and any changes
■ Literature review (critiquing other research in the that were made as a result.
field). ■ Results (all appropriate data displayed clearly).
■ Methods: ■ Discussion (analysis of the findings, stating clearly
A description of the methods used for collecting the the limitations of the study).
information and the reasons for selecting these ■ Conclusion (with recommendations for further
methods. research).
A description of the population sample studied, the ■ References (listing source material).
sampling methods and response rates.
is often a matter, in practice, of getting the right each stage of the planning/evaluation cycle, which
balance between alternative activities; for example, we described in Chapter 5.
in health education about smoking, getting a Strengths and weaknesses will be revealed, and
balance between national advertising and local ways of overcoming weaknesses will be identified.
facilities to help people stop smoking. Audit can involve either an internal review by the
people responsible for delivering a service or
scrutiny by an independent external auditor. For
Cost–benefit analysis
examples of clinical audit see the National Clinical
This is the process of comparing benefits with costs. Audit Support Programme (NCASP) at the NHS
Failing the cost–benefit test does not mean that an Information Centre (http://www.ic.nhs.uk).
activity is not worth investing in, but it does mean The audit cycle in Fig. 7.2 starts with the specifi-
that the cost of pursuing these benefits, in terms of cation of standards or criteria, followed by the col-
other benefits that will have to be forgone, cannot lection of data, the assessment of performance
be justified. Formal cost–benefit analysis is a and the identification of the need for change and
complex process, not least because it is difficult to implementing the improvements.
decide how different benefits should be measured It is in the nature of cycles that you can, in prac-
and valued. Nevertheless, it can be useful to apply tice, start anywhere. So you might start with collect-
the basic concepts of analysing the costs and the ing data on performance, assess performance and
benefits when you are allocating resources and recommend the need to specify standards. The dif-
evaluating results. (See Mason et al 2008 for an ficulty with auditing health promotion practice is
account of the difficulties of applying cost–benefit that it is often embedded in other work. For example,
analysis to heath promotion interventions at the audit of health promotion in clinical settings may
community level.) involve scrutinising issues about relationships and
communication, all of which are vital to the quality
of health promotion work, but may not relate spe-
Cost-effectiveness analysis
cifically to clinical audit.
This means comparing the costs and outcomes of
alternative activities to achieve the same goal (see
Vijgen et al 2007 for an example of a cost-effective-
ness analysis of smoking cessation programmes in
schools). It can be used when it is possible to Identify key
measure the outcomes of alternative activities in aspects of
the same unit of measurement, such as measuring performance
blood pressure. For example, supposing that
research had shown that exercise, drugs and diet (or
a combination of these) were effective in lowering Implement changes Specify standards
high blood pressure, these interventions could then or criteria to measure
be costed to see which ones were the most cost- performance
effective. This approach is used in considering alter-
native health interventions.
At a national level, NICE, funded by the Identify changes
Department of Health, undertakes this kind needed to improve Collect data on
analysis. performance performance
Audit
Assess performance
Audit is the systematic examination of the opera- (compare practice
tions of a service, followed by the implementation with standards/criteria)
of recommendations to improve quality. Basically,
an audit will scrutinise how the service carries out Fig. 7.2 An audit cycle.
For further reading on quality standards see Chapter 8, plans and supervision, since these are all related to
section on working for quality. audit.
Many of the tools described in the section on See the section on working for quality in Chapter 8.
research in this chapter can also be used in audit.
So, for example, you could use a telephone
survey after discharge to study the satisfaction
of patients with information and education they Health Impact Assessment
received as inpatients. When telephoning patients,
you would need to reassure them that participation Health impact assessment (HIA) is a relatively new
in the survey is voluntary, and that their comments approach, which accepts that social, economic and
would be completely confidential. The sort of environmental factors, as well as genetic make-up
questions you might like to ask are set out in and health care, make a difference to people’s
Box 7.2. health. It is a systematic way of assessing what dif-
ference a policy, programme or project (often about
social, economic or environmental factors) makes to
people’s health. For example, it has been used when
public sector organisations have wanted to under-
Audit, Research and Evaluation
stand the effect on people’s health of policies on
Audit, research and evaluation are complementary transport, air quality, economic development,
activities. Research is concerned with generating regeneration or housing.
new knowledge and new approaches, which can The assessment can be carried out before, during
be applied beyond the specific context of the study. or after a policy is implemented, but ideally it is
Evaluation involves making a judgement about done before, so that the findings can inform deci-
one specific intervention or project, which is the sions about whether and how to implement the
focus of its concern. Audit seeks to improve the policy. Key steps are to:
performance of a continuing service, such as an ● Select and analyse policies, programmes or
environmental health service or a midwifery projects for assessment.
service, through reviewing its practice. All three are
● Profile the affected population – who are likely
crucial to the pursuit of evidence-based health
to be affected and their characteristics.
promotion.
● Identify the potential health impacts by getting
You should not need to do a detailed evaluation
information from the range of people who have
of everything you do, because you may be basing
an interest in the policy, or who are likely to be
what you do on techniques and materials that have
affected by it.
already been evaluated by others and form part of
the published evidence. What you should do is to ● Evaluate the importance, scale and likelihood
audit your health promotion practices regularly to of the potential impacts.
check whether what you have planned and the ● Report on and make recommendations for
techniques you have chosen are working properly. managing the impacts.
If you need further training in how to carry out (See Kemm et al 2004 for discussion of the concepts
an audit of your health promotion practice, it and principles of HIA and the HIA gateway (http://
would be worth finding out about local opportuni- www.dh.gov.uk) for advice and tools on conduct-
ties for training in clinical audit as the basic con- ing HIAs including the National Audit Office (2009)
cepts can be applied to health promotion. Another guidelines.)
area to pursue could be training related to measur-
ing and improving quality or quality assurance.
PRACTICE POINTS
Quality cycles and audit cycles are very closely
related and the purpose of audit is to improve ■ It is important to identify how your health
quality. You could also discuss, with your manager, promotion work contributes to local and national
local arrangements for performance appraisal strategies. Your effectiveness depends not only on
(mechanisms for checking on and improving the what you do but also on how well your work
performance of staff), professional development complements that of other health promoters.
■ All health promoters have a duty to appraise ■ All health promoting services should regularly
evidence and to base their work on evidence of undertake audit: take stock of how they operate and
effectiveness where it exists. identify how things can be improved.
■ Doing research involves specialised skills, and you ■ If your work involves making or implementing
should aim to develop the appropriate competencies policies that affect people’s health, health impact
that the particular type of research requires. assessment may be a useful tool.
■ You need to consider whether you are getting value
for money, through using the ways of thinking
developed in health economics.
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107
Chapter 8
Skills of personal effectiveness
Summary
Chapter Contents
This chapter is about developing skills to effectively
Management skills in health promotion 107 manage your health promotion work. A number of
skills are covered including managing information;
Managing information 108
report writing; time management; project
Writing reports 108 management; change management; and finally,
working for quality. Case studies and practical
Using time effectively 110
exercises are included to illustrate and give the
Managing project work 111 context in which health promotion skills are applied.
Managing change 114
Working for quality 117
Working effectively in health promotion requires a
clear view of your aims and plans and the necessary
competencies to implement your goals.
See also Chapters 5, 6 and 7 for details on planning for
health promotion.
Management Skills in Health

Promotion
It is not easy to define what management is, but in

general terms it is about adopting practices which
ensure effectiveness and efficiency in your work.
Effectiveness means producing effects and accom-
plishing your goals. Being efficient means produc-
ing results with little wasted effort. It’s the ability
to carry out actions quickly. However, by being effi-
cient you may not necessarily be achieving effec-
tiveness, so it is important to establish the correct
balance.
A comprehensive introduction to management is
beyond the scope of this book, but for further details
you may wish to consult Boddy (2005) for general

EXERCISE 8.1 What information do you need
management and Longest (2004) for health service to store?
management.
Some aspects of management have already been Make a list of all the types of information you collect at
covered, such as setting priorities and planning. A present and analyse it by asking yourself the following
number of other managerial skills you will need to questions about each one.
be effective and efficient as a health promoter are 1. Do I need to keep this information?
outlined in this chapter. However, it is important to 2. How easy is it for me to find the information
emphasise that possessing these skills will not auto- when I need it?
matically make you effective and efficient. Other 3. Could someone else, or another information
factors also influence this, including: system, keep the information for me?
4. Who else might need access to this information?
● How well you integrate ethical principles into How easy would it be for them to find it?
your basic everyday work; how you exercise 5. How could this information best be stored?
your responsibility as a health promoter.
‘Response-ability’ is your ability to choose your
response and is a product of your conscious
choice, based on values, rather than a reaction
to your circumstances. Think about who else collects information in
your workplace and how they store it. Is there a
For further reading on ethics and values in health
central filing system? Does it work? Which informa-
promotion, see Chapter 3.
tion could and should you keep centrally? Under-
● The people you work with. Your effectiveness take Exercise 8.1 to enable you to identify what
and efficiency are limited or enhanced by the information you need to store.
competencies and motivation of those you
work with, for example receptionists,
Principles of Effective
secretaries, colleagues and others within and
Information Systems
outside your organisation.
● Your organisation. Both the structure and When reviewing or setting up your information
culture of your organisation will influence what system, it is useful to keep reminding yourself of
you are able to achieve. three basic principles:
● The wider world. The state of the economy, 1. Keep it simple! Systems are only as effective as
government legislation, the organisation of the people who put in and take out the
local government and the impact of social information. The simpler the system the more
trends are just a few examples of factors in the likely it is that busy people will use it correctly.
world outside your organisation that influence 2. Do not devise any more systems than are
how effective you can be. absolutely necessary.
This book is designed to increase your awareness 3. Organise systems so that anyone who might
of these wider influences on your work, as well as want to use them can easily understand them.
to develop your own competencies.
There are some key aspects of personal effective-
ness which will help you to manage health Writing Reports
promotion.
Important information is often conveyed through
written reports. For example, you are likely to need
Managing Information to write a report on plans for health promotion, or
an evaluation report on a specific project. You may
Whether you keep information on computer and/ need to write reports for your manager or formal
or a manual filing system it is easy to be swamped reports for committees. Written reports are likely to
by documents and papers, so keep only what is be read when you are not there, so there is no imme-
essential and cannot be kept by someone else or in diate feedback about whether the key points have
another existing system. been understood. To reduce the danger of being
Chapter 8 Skills of personal effectiveness 109
misunderstood, good skills in preparing and writing summary needs to set out the essence of the
reports are essential. report clearly and concisely. It is sometimes
referred to as the executive summary.
See Chapter 10, section on written communication skills.
● Introduction – this sets the context for the
Work through the following stages each time you report, for example why the work was
prepare and write a report. undertaken.
● The main body of the report – this will be the
Stage 1: Define the purpose bulk of the report. You need to break up the
content into sections and subsections, all with
To help to clarify the purpose, complete the follow-
clear headings. Headings should be signposts
ing sentence: ‘As a result of reading this report, the
to help the reader to see a route through the
reader will …’ What?
document and have an overview just by
The purpose could be to inform, to influence
skimming through the headings. Sections need
decision making, to initiate a course of action, or to
to be ordered in a way which will be logical for
persuade. Whatever it is, keep it clearly in mind
the reader. It may help to organise material into
throughout all the later stages.
sections by writing all the possible headings
and sub headings down, then move them
Stage 2: Define the readers around until you are satisfied that they are in
Identify the readers and consider them at all stages. the most logical order. You could use a
Direct the report to the needs and interests of the numbering system for each section, heading
readers. What do they already know about the and subheading, e.g. 1, 1.1, 1.1.1.
subject? How much time do they have for reading? ● Conclusions – summarises the conclusions
What kind of style is appropriate, for example, which can be clearly drawn from the
formal or informal? information in the report.
● Recommendations – these relate to the future,
Stage 3: Prepare the structure and summarise any changes needed.
● References – putting any references at the end
Decide on the structure of the report. A report nor- makes the report easier to read.
mally contains the following sections:
● Appendices – a misused feature of some
● Title – this should accurately describe what the reports, to be avoided unless really necessary.
report is about. Ask yourself ‘What information will most of
● Origins – for example the author’s name, my readers need the first time they read this
occupation, work base and date. report?’ If they need this information straight
● Distribution list – it is a great help to readers if away, put it in the main body of the report.
they know who else has seen the report. They
may detect that someone vital has not received Stage 4: Write the report
a copy.
Tackle the various sections in the order that makes
● Contents list – a long report will need a
it easiest. For example, it may be easiest to write the
contents list, showing the main sections of the
detailed body of the report first, then summarise
report and the pages on which the reader can
the information, then discuss the information, then
find them. This is not necessary for short
draw your conclusions, then set out your recom-
reports.
mendations, then write the summary of the report
● Summary – this is vital for all except the very
and lastly finish it off with the title, contents list,
shortest of reports (less than a page or two).
origin, distribution list and other essential details.
It helps the reader if the summary is easy to
find at the beginning of the report. Remember
that busy people will often read only the
Stage 5: Review and revision
summary (and perhaps the conclusions and After the draft report has been produced, review it
recommendations), or at least read the and revise as necessary. Make sure pages are num-
summary first in order to decide whether it is bered and check that sections and subsections are
worth spending time reading any more. So the correctly numbered. It is a good idea to get a
EXERCISE 8.2 Analysing and improving your use of time

1. Devise a recording format that suits you, ■ How much of your time do you spend on different
based on the example below activities? Does this reflect the importance of the
different activities? Important activities are those
Then photocopy or print out a supply of the sheets. Use as
that help you to achieve your objectives.
many sheets as necessary each day. Remember to include
■ Which jobs did not get done? Does it matter? Did
any work you do away from your organisation, for
you finish all the important and urgent jobs?
example at home.
■ How much time do you lose through interruptions?
If you discover that a particular activity, for example
What sort of interruptions?
telephone interruptions, is causing you a problem, then
■ How much of your time is spent on other people’s
make a detailed log of what happens each time. Do this
work?
immediately – do not leave it till the end of the day.
■ Do you do the right job at the right time? Most
Keep the diary for at least a week. If none of your weeks
people have a time of day when they work best. Do
are typical you will need to keep the log for several
you use this time for your most important work?
weeks.
Using codes will save you time. For example, you could 3. Now plan how to improve your time
use M for meetings, I for interruptions, P for phone calls, management
IP for phone interruptions.
Some of the changes you could make will be obvious. For
Time diary example:
Day _________ Date _________ Page no._________ ■ You discover that jobs started early in the morning
Activity Time spent Comments tend to get completed quickly. So you decide in
_____________ _____________ ________________ future to do your most important work at this time.
_____________ _____________ ________________ ■ You discover that you spend about 8 hours each
_____________ _____________ ________________ week handling interruptions. You decide to
experiment with techniques to cut down this time.
2. Now analyse how you used your time
■ You discover that urgent jobs are generally done
Each week, analyse your use of time by answering the but important long-term projects tend to be
following questions: neglected. You decide to make realistic plans to
■ How did you actually use your time compared with ensure that these jobs will be done.
how you planned to use it? ■ What else can you do?
colleague to proofread the report, someone with effectiveness by looking at how you use your time.
good report writing skills who will give construc- Time is an expensive resource, and the one that
tive comments. some may find the hardest to manage. First of all,
you need to know where your time goes. Exercise
Stage 6: Final check 8.2 and the next section are about analysing and
improving the use of your time and scheduling
Always do a final check for writing and typing
your work appropriately.
errors, spelling and other mistakes. It can be helpful
to ask someone who has not seen the report before
to check it for typing and layout errors. For further Time Logs and Time Diaries
information on how to write a report consult the
A time log involves keeping a record of how you
online How To website (http://www.howtobooks.
spend your time at regular intervals, which may be
co.uk).
as often as every 5 or 10 minutes. It is useful if you
wish to know exactly how you are using your time
Using Time Effectively on an activity that seems to be taking longer than
you think it should, and can help you to pinpoint
How well organised and effective are you at your the source of the problem. But keeping a log is time-
work? The following paragraphs should give you consuming itself, so is really worthwhile only if a
some ideas about how to improve your particular activity is causing you problems.
If you want to know more about how you gener- boring, try setting aside regular, small
ally use your time you can keep a time diary. This amounts of time to complete specific bits.
records how you have spent your time day by day Dividing it into manageable segments will
and should take only a few minutes to fill it in at help you to see that you are progressing.
the end of each day. If you have a short memory – Estimate how long each part will take to
you might find it better to fill in your diary more complete. It can be difficult to estimate how
frequently, say at the end of the morning and at the long it will take you to complete a particular
end of the afternoon, or at any other convenient task, but an informed guess will at least help
break between blocks of work. you to be more realistic in future. Here are
some suggestions that may help:
• use your experience from similar jobs
Scheduling Your Work • consult colleagues who have experience in
See Chapter 6, section on setting health promotion doing the job
priorities. • build in some contingency time
• keep a note of how long the task actually
Health promoters can find that they have to do far
takes, so that you can make a better
more than their time permits, and that they are
estimate next time.
faced daily with too many requests and demands.
This means that, first and foremost, they must be – Schedule in your diary or organiser when
very clear about their priorities. Second, they must the work will be done. You may find that
be assertive about saying ‘no’ to requests to take on you need to reschedule daily, to take account
nonpriority tasks. Third, they need to develop skills of changing priorities. The important thing is
of organising time and scheduling work to ensure to ensure that the key tasks you need to
that work which should get done actually does undertake are scheduled to allow enough
get done. time for their completion. For more tools and
Scheduling work into the time available involves tips on effective time management see Evans
three steps: (2008).
1. Identify how long you need to spend on a job.
This depends on:
Managing Project Work
– The nature of the activity; for example,
whether it is possible to reduce the time
Planning and managing a project can be different
allowance without endangering people or
from other managerial activities. When you are first
the outcomes.
given responsibility for a project, it can seem rather
– How important the job is. If it is daunting. You must turn something that does not
unimportant it does not merit a large yet exist into reality, and control its progress so that
investment of your time. Ask yourself ‘What it delivers effectively and efficiently.
am I employed for? Will doing this job The most obvious thing about a project is that it
contribute to my main aims and objectives?’ has a particular (unique) purpose, which may be
If not, it is unimportant. If the job is encapsulated in its name, such as ‘Bromley Active
important it merits a large investment. Lifestyles Project’ or ‘Portsmouth Needle Exchange
2. Identify how soon you need to have the job Project’. It is probably most useful to think of a
completed. This depends on how urgent it is. project as an instrument of change, which, when it
Urgent jobs are ones that have imminent is successfully completed, will have made an impact
deadlines. If an urgent job can be completed as defined in its aims and objectives.
quickly, deal with it right away. That means it Another key aspect of projects is that they are
will not interfere with you getting on with the time-limited: they have clearly identifiable start and
most important jobs. finish times. Projects vary enormously in their
3. Plan when the work will be done. This involves scope. Small projects can last only a few days and
the following steps: involve activities by a single person; large projects
– Break the job down into manageable parts. If can involve many people (and indeed many agen-
the job is big or difficult, or parts of it are cies) and last for several years.
BOX 8.1 The stages of a project Starting a Health Promotion Project

1. Start is the most important stage of any project A project will start with a proposal or written docu-
and covers areas such as setting the overall aims, ment, which can take a number of forms, such as
gaining approval and the allocation of a budget. ‘terms of reference’ or ‘report of a feasibility study’.
It will set the foundations for the lifetime of the The key elements that must be described in this
project. document include the following:
2. Specification involves defining the detailed ● Who is proposing to carry out the project, for
objectives of the project, i.e. what the outcomes example, a primary care trust or voluntary
will be and the targets for delivering these organisation.
outcomes in terms of quantity, quality and ● Who is the purchaser or commissioner of the
timing. project, for example the local authority.
3. Design stage is when the ‘what’ is translated into ● The aims and outcomes of the project.
‘how’. It may take the form of detailed plans. ● The scope of the project, for example who will
4. In the implementation stage the plans are put use or receive it, the setting in which it will be
into operation. It is important to note that the delivered, which departments, agencies and
end of implementation is not the end of the people will be affected.
project.
● The costs of the project, in terms of staffing,
5. The evaluation, review and final completion
buildings, equipment and other resources.
stage will be marked by delivery of the final
● The project stages or milestones with timescales.
report, which includes evaluation of the findings
and the details of a post-implementation review. ● Methods and standards: the use of any
This review should take place some time after the particular techniques or methods and the
end of the implementation stage, so that it is adoption of any recognised quality standards.
possible to include data on the long-term ● Roles and responsibilities of participants in the
outcomes of the project. project (especially important when the project
is commissioned by a partnership of a number
of agencies).
Detailed Planning
All projects, however, have the same basic under-
For anything but the very smallest of projects, you
lying structure and go through a number of stages,
will need to develop a detailed plan of each stage
as set out in Box 8.1.
immediately before you enter it. Typically, one of
These stages are, of course, very similar to the
the last tasks in the planning of a stage will be
basic planning and evaluation cycle that was
planning the next stage. The Gantt chart, named
described in Chapter 5, and you should read the
after Henry Gantt, the man credited with its inven-
present section in conjunction with Chapter 5. The
tion (http://www.ganttchart.com), is the primary
difference is that when you are delivering an on-
tool to use for planning, scheduling and monitoring
going service, rather than a one-off project, the cycle
project tasks.
repeats itself over and over again.
The Gantt chart is made up of a task information
See Chapter 5, Planning and evaluating health side (on the left) and a task bar side (on the right)
promotion. (See Fig. 8.1 for an example). The task information
side sets out the nature of each task and the person
Because projects vary so much in terms of their
or people responsible for it. The task bar is a line
scale and length of life it is particularly important
that represents the period during which the task
that they are planned systematically. It is also
will be carried out. The precise content of a Gantt
vital to understand how the project contributes
chart should be determined by the intended use.
to the wider strategic plans of the organisation
Such a chart is easy to draw and presents the plan
concerned.
in a visual form, which is easily understood by most
See Chapter 7, section on linking your work into broader people (see http://www.ganttchart.com for exam-
health promotion plans and strategies. ples of Gantt charts and available software).
PM = Project Manager Feb March April May June July Aug Sept
R = Researcher
Recruit pharmacists (PM)
Appoint research worker

(PM)
Design and pilot interview

schedule (PM + R)
Design training (PM)
Do 'before' interviews
with pharmacists (R)
Train pharmacists (PM)
Action phase by
pharmacists
Do 'after' interviews
with pharmacists (R)
Write research report

(PM + R)
Fig. 8.1 An example of a Gantt chart (see also Case Study 8.1).
The chart can be used at every level in the plan- planning you are unlikely to be able to keep your
ning process, from initial outline planning down to project on course at all. Case study 8.1 describes the
the detailed planning of individual tasks. For use of the Gantt chart in Fig. 8.1.
complex projects any single bar on the master chart
for the whole project might have to be represented
Controlling Implementation
by a more detailed bar for that particular task or
stage. In addition to detailed plans, a project needs to have
One major benefit of Gantt charts is that they built-in control procedures. Controlling projects is
highlight critical points, for example where pro about identifying problems as soon as they arise,
gress in X is dependent on Y already being working out what needs to be done to ameliorate
completed. them, and then doing it. Things that need to be
Planning tools such as Gantt charts are only aids controlled include time, the budget (costs) and
to help you to achieve your purpose. Sticking to quality. Methods for control include progress
your plan will not necessarily bring success; you reports and one-to-one and group progress meet-
may have to make adjustments because of unfore- ings. Large projects will need to use all of these
seen circumstances. However, without systematic methods. Progress reports can sometimes be best
CASE STUDY 8.1 USING A GANTT CHART Managing Change

IN PROJECT PLANNING
Health promoters may experience change in two
This small pilot 8-month project aimed to explore
ways. One is being a part of an organisation that is
the feasibility of using community pharmacists to
undergoing change, hence finding yourself being
promote physical activity with customers. Its
reorganised. The second way is by being a change
objectives included identifying barriers and
agent, by initiating and implementing changes in
opportunities, and seeing whether training helped.
health promotion policy or practice.
The plan was to recruit 10 volunteer pharmacists,
The first way, experiencing organisational
interview them to ascertain their attitudes towards
change, is common in statutory agencies as mod-
promoting physical activity with customers and their
ernisation and reorganisation affect the NHS and
current practice, and then work with them in a
local authorities in particular. Understanding and
training session. After the training, the pharmacists
surviving organisational change is outside the
had a 6-week period to implement the training,
scope of this book (see Baker 2007 for an overview).
followed by another interview to see if their attitudes
However, understanding how to implement change
and actions had changed.
successfully is a fundamental part of a health pro-
A project manager had responsibility for planning
moter’s role.
and managing the project; a researcher was employed
to design and carry out the interviews and help with
the final report. Implementing Change
Fig. 8.1 shows the Gantt chart drawn up by the
project manager. It was useful for clarifying what You may want to introduce a change in your public
needed to be done when, and for seeing when health practice, such as a different way of running
possible timing difficulties could arise. For example, health promotion programmes, introducing a
would pharmacists’ or researchers’ holidays interfere health-related policy at your place of work or start-
with the schedule? Were there too many tasks to be ing off new health promotion activities. Implement-
completed at one time (for example, recruiting ing change can be very challenging, and it will help
pharmacists and appointing the research worker in to spend some time thinking through your
February and March)? The Gantt chart also showed strategy.
which stages required the research worker, so that
the project manager could negotiate the appropriate
numbers of hours worked at appropriate stages.
Key Factors for Successful Change
The key to gaining commitment to change, and
overcoming resistance to change, lies in under-
standing the motivation of all the people who
presented in a standardised form, which compares could be affected by the change and how they feel
progress with the project plan. about it. Overall, do they feel positive or negative
about the proposed change? The balance between
For more about quality, see section on working for
positive and negative factors can be expressed in
quality later in this chapter.
the change equation in Box 8.2 (Gleicher 1990)
Some problems will be outside the immediate developed as a tool to help analyse the key factors
control of the project. For example, a project could involved.
be influenced by the training policies of an organi- The basis of the equation is the simple assump-
sation or other factors deeply embedded in the tion that people are rarely interested in change
structure and culture of an organisation. In these unless the factors supporting change outweigh the
cases project managers should do what they can to costs. As a change agent your job is either to reduce
reduce the impact of these issues on the project, but D (the perceived costs) or to increase the sum of
should also remember that they have a duty to A, B and C:
highlight these issues in reports. There are many A: Dissatisfaction with the way things are. If you are
books on project management that offer detailed dissatisfied, you may wrongly assume that others
advice for those managing a project for the first are too. If people are comfortable with the way
time. A good example is Lock (2007). things are they are unlikely to support change.
B: A shared vision of a better future. If a vision of a threatens their livelihood or other cherished aspects
better future does not exist, or is unclear, people of their lives. A vision that threatens important
will not strive to achieve it. If there are several com- aspects of an individual’s or a group’s life is almost
peting visions, energy will be dissipated in argu- bound to fail.
ments. Few people would buy into a vision that C: An acceptable, safe first step. The size of the
change and the risks involved can seem overwhelm-
ing. Many of us could share a common view of
what better health for all would mean. But where
BOX 8.2 The change equation do we begin? First steps are acceptable if they are
A = the individual’s or group’s level of dissatisfaction small, are likely to be successful or, if they fail, do
with things as they are now. not cause too much damage and the situation is
B = the individual’s or group’s shared vision of a retrievable.
better future. D: The costs to the individual or group. What is impor-
C = the existence of an acceptable, safe first step. tant here is how people perceive the costs. There will
D = the costs to the individual or group. always be costs and change can be perceived as
Change is likely to be viewed positively, and be difficult or unfair. Costs can be tangible things like
implemented successfully, if: A + B + C is greater time, money, resources, or more intangible costs like
than D. stress or loss of status (see Case study 8.2 for an
example of A–D reflected in a change in practice).
CASE STUDY 8.2 CHANGE IN A LOCAL HEALTH CENTRE

An example of significant change originating from a Centre to be located in the foyer of the health centre
few people started with a physiotherapist working in which will include a computer for online access to
a local health centre. Many of her patients were specific websites that are recommended by the
elderly and suffering from arthritis. She found that, in practice staff.
addition to giving instructions verbally, it was useful This case study illustrates the factors in the change
to write down instructions for the people she saw equation:
who needed to comply with exercises at home. She A. The individual’s or group’s level of dissatisfaction
enlisted the help of a friend who was a graphic with things as they are now: two of the
designer in designing and printing some leaflets based physiotherapists and the receptionist, and through
on her advice and instructions. A second them the practice manager, saw that there was
physiotherapist had begun to collect a small library of room for improvement.
books, such as those produced by the Arthritis and B. The individual’s or group’s shared vision of a better
Rheumatism Council, which were left in the waiting future: the idea of improved help for patients was
room. A list of recommended books was added to the shared and spread through an increasing number
leaflet. Meanwhile, the receptionist had taken another of people in the health centre and other health
initiative. A friend had told her about a local support centres locally.
group for arthritis sufferers, and she pinned up C. The existence of an acceptable, safe first step: this
a poster, giving information about it, in the change was built on a number of small successes,
waiting area. and did not present any major hurdles which could
The practice manager encouraged the staff to have induced resistance. If the first step had been
share their ideas. As a result a strategy to improve the to propose a Patient Education Centre, people may
provision of information to patients was launched, well have perceived major difficulties.
and patients were asked about their needs and D. The costs to the individual or group were small in
preferences. the first instance; just a little time and effort. By
Other health centres heard about the venture and the time major investment was required for the
expressed interest. As a result, a number of other Patient Education Centre, everybody was
initiatives took place to improve patient information. committed.
Plans are now underway for a Patient Education
Reasons for Resistance to Change approaches, for the situation and the people
involved. Five possible options are given below.
People react differently to change. While one person 1. Education and communication. This involves
may passively resist a change, another may actively educating people about a change before it happens
try to sabotage it, whereas a third may actually and communicating with them in a variety of ways,
embrace change. Whether you are campaigning for including one-to-one, group discussion and written
a change, or implementing a change in policy or documents. An educational and communication
practice in your work, you will need to deal with approach is indicated when resistance to change is
the fact that many people will have reasons to resist based on inadequate or inaccurate information. The
change, including the following. limitation is that it can be time-consuming, espe-
Self interest. While a change may be in the inter- cially if a lot of people are involved.
est of most people, it may not be in everyone’s best 2. Participation and involvement. Resistance to
interest. For example, while most people, including change may be forestalled if those initiating the
some smokers, may support a smoking policy, change identify the people that they think will be
others may see it as an infringement of personal resistant, and actively involve them in the process
liberty. of designing and implementing the change. The ini-
Misunderstanding. The change being proposed tiators of the change must genuinely be prepared to
may be misunderstood. For example, some may listen and learn. A token effort is liable to provoke
think that an alcohol policy is allowing people with more resistance, because people will feel let down
drinking problems to have different standards of if their contribution is not taken seriously.
work performance and behaviour than the rest of Participation and involvement are necessary
the workforce. Misunderstandings are particularly when full commitment to a policy change is needed
frequent in organisations where there is a lack of in order to make it work; policies work when people
trust between the managers and the workforce. feel ownership for them because they have been
Belief that a change is not in the interest of the people involved in their development. This approach is
it is intended to benefit. People may believe that the also useful when the initiators do not have full
costs of a change will outweigh the benefits, not information about the implications of the change
only to themselves but also to others or a whole for certain groups of people or certain departments.
organisation. For example, people may feel that the It could also be the preferred option where the
introduction of ethnic monitoring as part of an initiators of change have little power, because it
equal opportunities policy could actually increase harnesses the power of others as a force for change.
discrimination against black and minority ethnic Nevertheless, this approach does have limita-
groups. tions. It is very time-consuming and demands a
Awareness of these opinions is important for the high degree of coordination. It can lead to a poor
policy maker, because they may be based on know outcome if an attempt is made to accommodate
ledge of what goes on in parts of the organisation everyone’s needs.
with which the policy maker has little contact. 3. Facilitation and support. This involves helping
Policy formation must be based on an accurate people to identify what changes are required and
analysis of the situation; this is particularly relevant providing them with support to plan and manage
in large organisations, like the health service and the change themselves. This could be done, for
local councils. example, by providing time for people to reflect on
Low tolerance for change. People may resist change the situation, and to identify their own objectives
because they are anxious about new demands that and how to meet them. Support could include emo-
will be made of them. Organisational change can tional support to cope with the stress of change, and
require people to change too much, or fail to provide the development of mentoring schemes, where
them with the time and support they need. more experienced people help others with their
managerial or professional development. This
approach works best where anxiety and fear lie at
Methods for Overcoming Resistance
the heart of resistance. The limitation of this
to Change
approach is that it, too, can be time-consuming and
In order to overcome resistance to change it is vital expensive (for example, if it is necessary to employ
to select the best approach, or combination of counsellors for a large workforce).
4. Negotiation and agreement. This involves offer- Criteria for Quality
ing incentives to actual or potential resisters, for
example, through negotiating with trade unions What are the criteria for quality in health promotion
about the effects of the change on working condi- work? The checklist in Box 8.3 may be helpful in
tions. This is particularly appropriate when it is identifying aspects of quality in your health promo-
obvious that some people will lose out as a conse- tion work. The checklist can be applied to your
quence of the changes. It can be effective if there work overall, or to a particular health promotion
are specific pockets of resistance, but could be programme.
expensive if everyone argues that they are also
losing out. Improving Quality
5. Political influencing. This approach can be
Initiatives to improve quality are usually successful
useful where one, or a few, powerful individuals
if people work together to pool ideas. This could be
are the source of resistance. It can be relatively
a group of people authorised by management to
quick, but has the drawback that it can lead to prob-
examine a particular issue or problem, such as
lems in the future if people feel that they have been
improving the quality of patient information litera-
manipulated.
ture, the way in which antenatal advice is being
See also Chapter 16, section on the politics of influence. given to prospective parents, or the way a GP prac-
tice is helping patients to stop smoking.
Sometimes such groups are called quality circles.
These are work groups of between three and 12
Working for Quality employees who do the same (or similar) work,
who meet regularly to address work-related prob-
Working for quality involves examining the nature lems. The issues to tackle are selected by the group
of the service and assessing how good it is when itself and the outcomes are presented to manage-
judged against a number of criteria. ment. In many cases the group is also involved in
BOX 8.3 Checklist: Criteria for quality in health promotion

1. Appropriateness: is it relevant and acceptable 6. Environment: does it ensure an environment
to clients – the individual, group or community conducive to people’s health, safety and
concerned? wellbeing? Does it recognise that people feel at
2. Effectiveness: does it achieve the aims and home in different environments, and may feel
objectives you set? uncomfortable or intimidated in some settings?
3. Social justice: does it produce health improvement Is the social environment friendly and
for all concerned, not for some people at the welcoming?
expense of others? In other words, is it ‘fair’? 7. Participant satisfaction: does it satisfy all those
4. Equity and access: is it provided to all people with an interest in the outcomes of the health
whatever their racial, cultural or social background promotion work, such as commissioners,
on the basis of equal access for equal need? (This managers, clients and other interest groups,
may mean, for example, unconventional clinic times, acknowledging that the views of clients should
wheelchair access, leaflets in Braille and ethnic be paramount?
minority languages, information on audio and video 8. Involvement: does it involve all those with an
cassettes, etc.) interest, including clients, in planning, design and
5. Dignity and choice: does it treat all groups of implementation? Does it avoid ‘tokenism’, with
people with dignity and recognise the rights of clients’ views genuinely sought and incorporated in
people to choose for themselves how they live their a nonpatronising way?
lives? Is it nonjudgemental, accepting that people 9. Efficiency: does it achieve the best possible use of
have the right to withdraw from, or reject, health the resources available, and provide value for
promotion if they so wish? money?
implementing the solutions. Management commit- ● Accurate, up-to-date information informed by

ment to taking account of the outcomes and imple- evidence.
menting recommended changes is crucial to success. ● Free of inappropriate advertising.
Typically, a quality circle will:
See section on guidelines for selecting and producing
● Begin by drawing up a list of issues for health promotion resources in Chapter 11.
consideration, using techniques such as A further challenge is to develop standards that
brainstorming. are quantifiable in some way. This is a difficult
● Select the issue to be addressed. task, but you could, for example, develop a five-
● Gather information about the nature of the point scale for assessing the quality of your leaflets,
problem, and analyse the causes. so that you score them out of five for the extent
● Generate a range of solutions, and establish the to which they fulfill each quality standard. Another
best options or combination of options. example could be that you decide that a quality
● Prepare a report on their findings for management issue is to respond quickly to requests
management decision. from your clients. You could develop this by
setting a standard such as returning telephone
An example of a quality circle might be a group of calls within 24 hours, and written requests within
nurses working in a coronary care unit looking at 3 days.
how to improve the quality of the patient education Setting, monitoring and reviewing quality stand-
programmes which are run for discharged patients. ards can involve a great deal of time and effort.
The activities of such a group are described in Case The benefit comes from seeing clearly identified
study 8.3. improvements in service.
PRACTICE POINTS
Developing Quality Standards
■ To implement health promotion work successfully
It may be helpful to look at improving quality by
you need to develop management skills that include
setting specific quality standards, which are an
information management, report writing, time
agreed level of performance negotiated within
management, project management, managing
available resources.
change and developing quality.
Examples of standards that relate to public
■ Managing information involves storing in the
health and health promotion are available on the
simplest way the paperwork and electronic files that
National Institute for Health and Clinical Excel-
are essential and that cannot be kept in another
lence (NICE) website (http://www.evidence.nhs.
information-retrieval system.
uk). Quality standards in health promotion work
■ Writing a report involves being clear about the
have been developed (see, for example, Health
report’s purpose and following a coherent and
Development Agency 2004) and can be set for
logical structure. Always get your report checked
health promotion materials (see, for example, Haw-
prior to publication.
thorne et al 2009). The criteria listed below could be
■ Managing time involves monitoring your time
used as a list of quality standards for health educa-
through using time logs and diaries and scheduling
tion leaflets (see also Children, Youth and Women’s
tasks appropriately.
Health Service 2006):
■ Project work involves detailed and systematic
● Appropriate for achieving your health planning. A Gantt chart is a useful tool.
promotion aims. ■ Managing change requires an effective change
● Content consistent with the values of health

strategy and is more likely to be successful if
promotion. people have a shared vision and believe that the
factors in favour of the change outweigh the
● Relevant and easily understood by the people
costs.
for whom the leaflets are intended.
■ Working for quality is best achieved collaboratively.
● Involved the target audience to ensure it meets
Management support and involvement are essential
their needs. for success.
● Not racist or sexist.
CASE STUDY 8.3 BLOGGSVILLE ROYAL HOSPITAL: CORONARY CARE UNIT

Improving the quality of patient education ■ Setting up a video and audiotape library providing
A group of four nurses in the coronary care unit have appropriate material for discharged patients on
been meeting regularly as a quality circle, and have free loan.
decided to investigate how to improve the quality of ■ Offering opportunities for counselling by specialists
education for discharged patients. At present a course (dietitian, physiotherapist, psychologist) before
of six group sessions is provided for patients after discharge.
discharge, and nurses take turns to organise and run ■ Selecting or producing appropriate written
the courses. material, and making it available to patients before
The group first looked at the data for attendance discharge.
at the group sessions. They discovered that, over the ■ Inviting all patients to return for an open evening,
last year, 60% of discharged patients attended at with information and demonstrations about
least one session, but of these, only 20% attended facilities and activities available locally. This would
three or more sessions. include local authority exercise and leisure
They conducted a series of interviews with facilities, alternative medicine practitioners,
discharged patients to investigate the reasons for community and self-help groups and commercial
attendance or nonattendance, and to find out leisure organisations.
patients’ preferences about how they would like the The report includes a financial breakdown, which
education to be provided. They discovered that some demonstrates that the recommendations will have
patients do not like attending a group under any additional costs, primarily related to the proposed
circumstances, and some strongly dislike coming back services to be provided by the professions allied to
into the hospital environment. But some of these medicine. However, savings will be made on the
would like one-to-one opportunities for guidance nursing staff time currently devoted to running the
from specialists such as a dietitian (on healthy courses and through financial sponsorship of written
eating), a physiotherapist (on exercise and fitness) material by approved ‘ethical’ commercial sponsors.
and a psychologist (on how to stop smoking, stress This case study shows how the quality of the
management and relaxation). patient education programme could be improved on a
Other patients would prefer to have written number of criteria:
information, audiotapes (for relaxation and self- ■ Appropriateness: clients would find the new
hypnosis) and videotapes (of appropriate exercise approach more acceptable and relevant.
routines), rather than come back to the hospital. ■ Effectiveness: more clients would gain from the
Others would like more information about community programme.
groups and facilities for exercise tailored to their ■ Equity and access: clients could access advice and
needs: for example, free trials of fitness classes, help in different ways, and those who disliked
swimming sessions for elderly people. Others are group meetings, or found attendance difficult,
interested in knowing if there are self-help or would have their needs met in other ways.
voluntary groups they could join, such as clubs for ■ Environment: it was recognised that some people
people who are being rehabilitated following heart disliked the hospital environment.
disease. Some patients, especially those who are ■ Participant satisfaction: clients and nurses would
socially isolated, have particularly valued the be more satisfied with the results.
opportunity to meet as a group and to exchange ■ Involvement: clients were involved in redesigning
experiences. the programme, with their views taken into
After analysing these findings, the group of nurses account.
produced a report for their manager recommending ■ Efficiency: it would be a better use of resources
that a range of educational opportunities is provided because it would reach the people intended, and
for the education of discharged patients including: avoid wasting resources on a programme that
■ Putting patients in touch with local self-help and reached very few.
cardiac rehabilitation schemes.
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Evans C 2008 Time management for Health Development Agency 2004 Public%2bHealth&ps=10&pa=2&s=
dummies. Chichester, John Wiley Promoting children and young Relevance
& Sons. people’s participation through the http://www.ganttchart.com
Gleicher D 1990 Open Business National Healthy School Standard. http://www.howtobooks.co.uk/
School/Institute of Health Services http://www.evidence.nhs.uk/ business/reports
121
Chapter 9
Working effectively with other people
Summary
Chapter Contents
This chapter focuses on developing skills of working
Communicating with colleagues 122 effectively with other people and organisations in
order to plan and implement health promotion. The
Coordination and teamwork 122
following key aspects are discussed: communicating
Participating in meetings 124 with colleagues; coordination and teamwork;
participating in meetings; effective committee work;
Effective committee work 125
working in local partnerships for health with other
Working in partnership with other agencies. Practical exercises and a case study are
organisations 126 included.
Some health promoters plan and undertake their

health promotion work entirely on their own, but
most are likely to be working with other people
from the wide range of professional backgrounds
that make up the multidisciplinary workforce that
promotes health:
● Colleagues, who may be peers, managers or
people you manage.
● Colleagues in other parts of your own
organisation.
● People drawn from the community and/or
from different agencies (local, national or
international) who are working with you on a
health promotion activity of mutual interest
and importance.
A key aspect of success will be how well you work
with other people, and this chapter discusses the
knowledge and skills needed for interprofessional
communication and collaborative working.
increase your awareness of how you communicate

Communicating with Colleagues
with colleagues, and how your communication
might be improved.
Some fundamentals of effective face-to-face and
written communication are dealt with in Chapter
10. While these are presented primarily with client
contact in mind, they are also applicable to contact
Coordination and Teamwork
between health promotion colleagues. The follow-
Health promotion often involves multiagency
ing factors are particularly important to ensure
and multidisciplinary working, therefore effective
effective working relationships:
coordination and teamwork are required.
See Chapter 10. Poor coordination can result in losses in effi-
ciency and effectiveness of programmes; it is espe-
● Working in a team which recognises and builds
cially difficult when big bureaucracies like the
on the strengths of other team members.
NHS and local authorities are working together.
● Actively listening to the people you are
There are several ways of coordinating, and it
working with, so that you understand clearly is important to use the one best suited to the
their opinions, ideas and feelings. situation.
A considerable proportion of your time may be
taken up by communications with working col-
Appointing a Coordinator
leagues, including telephone conversations, face-
to-face discussions and written communications on A potential problem for coordinators is that they
paper and via e-mail. Try Exercise 9.1 to help may not directly manage the people they are trying
EXERCISE 9.1 How you communicate with colleagues

Record all the types of communication with colleagues that you carry out over one working day, by making a tally of all
the occasions in four categories, as set out below. Then add up your total for each category, and your grand total for the
day.
You might like to compare your results with those of your colleagues.
Face-to- Paper: letters Electronic: e-mail, Web

face verbal Telephone and memos cam/computer conferencing
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
TOTALS ________ ________ ________ ________
Think about whether there is anything you would like to change or improve; for example:
■ If you spend a lot of time on the telephone, could you improve your telephone skills?
■ Could you use your time more efficiently if you used less time-consuming methods of communications (for
example, phone or e-mail) instead of writing letters or having meetings?
■ Are there ways that you can use technology to communicate more effectively and efficiently with colleagues?
■ Do you need to selectively spend more time face-to-face in order to understand colleagues and establish a
closer working relationship?
Chapter 9 Working effectively with other people 123
to coordinate and therefore cannot control them in

EXERCISE 9.2 Improving coordination
the same way as a manager. They must convince and teamworking
people that any requests they make are legitimate.
Coordinators can be at a low level in a hierarchical In the health promotion work you do that involves
organisation. A diabetic nurse trying to coordinate working with other people, can you think of any ways
the production of a patient information leaflet, for by which you could improve coordination and
example, might find it difficult to obtain the com- teamworking?
mitment of a consultant. The very word coordinator ■ What steps could you take to enhance the
may provoke resistance to being organised in some reputation of your health promotion work?
people. ■ With whom could you build a better relationship
There are several tactics that can help to over- to improve coordination or teamwork?
come resistance. ■ What have you got to offer if you are bargaining?
■ Can you think of any health promotion activities
that you undertake routinely together with other
Using your reputation people which could be more efficient with a set
People will find it difficult to turn down any reason- procedure?
able requests if your work is well known and well ■ Are there any ways by which you could develop
regarded and you are respected by those who work stronger links with other staff at your level in
with you. So you need to publicise your work and different departments or agencies, to facilitate
seek to establish a good reputation. joint working in health promotion?
■ Have you any opportunities for joint objective
setting or joint planning that could help to
Establishing good relationships coordinate health promotion in your situation?
Building and maintaining good relationships ■ Can you think of anything else? Discuss this with
requires effort and is an essential investment for colleagues who are also involved in health
every coordinator. promotion.
Bargaining
It may be possible to bargain with individual people Policies, Procedures and Protocols
or departments: could you offer them something in
Making and implementing policies is discussed in
return for their cooperation?
Chapter 16.
Out-ranking Policies are increasingly important in coordinating

health promotion work. Using set procedures are
This should be used only as a last resort. It requires ways of coordinating routine tasks. Protocols are
a senior manager from your hierarchy to request agreed written procedures that everyone follows,
cooperation through the other person’s manager. ensuring that everyone carries out a particular task
While the other tactics build trust, this one endan- in the same way. For example, there may be a
gers it and may result in a lack of goodwill. smoking cessation protocol in a GP surgery about
how to help a patient to stop smoking. The protocol
ensures that whoever is dealing with the patient
Discussion and negotiation
(the doctor, the practice nurse, the district nurse or
Talking to all involved could result in clarification the health visitor) will offer the same range of help
of responsibilities and improved mutual under- and follow the same follow-up procedures (for an
standing, leading to the group giving you more excellent example of a smoking cessation protocol
legitimate authority. This could mean first discuss- see http://www.alhcc.scot.nhs.uk).
ing the issue with individuals, and later convening
a meeting when you have got sufficient commit-
ment to solving the problem. Undertake Exercise
Joint Planning
9.2 to assess how you might improve your coordi- In this approach the parties involved not only agree
nation and teamworking skills. objectives but also meet regularly to develop and
implement a joint plan. This may minimise the need

BOX 9.1 Characteristics of successful teams
for one individual to be given the job of coordinator
and prevent the problem of one agency or depart- ■ A team consists of a group of identified people.
ment being perceived as controlling the agenda. ■ The team has a common purpose and shared
However, it can be very difficult to get all the people objectives, which are known and agreed by all
involved together on a regular basis, and to ensure members.
that communications are always clear to all those ■ Members are selected because they have relevant
involved. expertise.
■ Members know and agree their own role and
know the roles of the other members.
Joint Working through ■ Members support each other in achieving the
Creating Teams common purpose.
■ Members trust each other, and communicate with
An autonomous team is given the authority, train-
each other in an open, honest way.
ing, money, staff, premises and equipment to carry
■ The team has a leader, whose authority is
out the health promotion programme. There is no
accepted by all members.
need for a coordinator, since the whole team is
working together from the same base. Joint working
of this kind is usually not suitable for short-term
programmes, but can be excellent for long-term
projects such as those involving community
Participating in Meetings
development.
The detailed planning and organisation of meetings
are beyond the scope of this book (see Barker 2006
Creation of Lateral Relations and Hadler 2006 for useful guidance on running
meetings). The guidance below is an aid to how to
This type of coordination depends on strengthen- be an effective participant at meetings. As a partici-
ing relationships between individuals in broadly pant there are a number of constructive things you
equivalent jobs in different departments or agen- can do:
cies. Setting up project teams, which are dissolved
● Encourage the Chair into good practices: for
once the particular project is completed, can do this.
example, ask for clarification on the purpose of
It could also be done by forming interdepartmental
the meeting, and ask for a summary of what
or multidisciplinary teams or partnerships, which
has been agreed at the end.
are given more authority for making decisions,
● Come prepared and arrive on time.
without having to refer them up the different hier-
archies. However, this can lead to conflict with the ● Acknowledge the authority of the Chair.
existing vertical lines of command, and works best ● Agree what to do about taking notes: does each
where there are good links between the various person take their own, or does one person take
managers. them and circulate a copy to everyone else? Do
you want detailed notes of everything you
discussed, or just action points?
Characteristics of Successful ● Actively contribute to the meeting, express
Teams your views succinctly, keep an open mind and
There are different sorts of teams. The teams of listen to other people’s opinions.
relevance here are associations of people with a ● Encourage everyone to participate by referring
common work purpose, for example a primary to members’ relevant experience or expertise.
healthcare team. Successful teams have the charac- ● Only make commitments that you are genuinely
teristics set out in Box 9.1. If you experience a team able to fulfill, and make sure you fulfill them on
that does not seem to be working well, it can be time. Say ‘no’ clearly and nondefensively if you
helpful for the team to consider this list together, to are unable or unwilling to take on a task.
identify the roots of the difficulties (for more infor- ● Remember that discussion and debate about
mation on how to develop successful team working ideas will help decision making but personal
see Jelphs & Dickenson 2008). rivalries will not.
The Secretary is responsible for compiling the

Effective Committee Work
agenda for the committee meetings. This is the list
of things to be done or agreed during the meeting.
A committee is a group of people appointed for a
It will often include standard items such as ‘apolo-
specific purpose accountable to a larger group or
gies for absence’, ‘minutes of the previous meeting’,
organisation: examples are the management com-
‘matters arising from the previous meeting’ and
mittee of a voluntary organisation or the health
‘any other business’. The important point is that the
committee of a local authority. There are many
agenda acts as an advance organiser for everyone
common routines and procedures that help facili-
attending the meeting, so that they are able to
tate committees, and it is useful to be familiar with
prepare. The committee members need to receive
them. The details will vary from committee to com-
the agenda and associated papers in good time
mittee, although the principles remain the same.
before the meeting, usually a week in advance.
Some committees start their life with recommenda-
The Secretary is also responsible for the final
tions from a steering group, which include propos-
version of the minutes, and for agreeing these with
als for the interim committee rules. These are then
the Chair, even if a Minutes Secretary takes the
approved at the first committee meeting. After
notes at the meetings. Minutes are accurate records
review and modification, a set of rules will be
of the meeting, and should always identify pre-
agreed which become the accepted rules for the
cisely who has responsibility for what action, by
committee.
what date, and when a report back will be made to
the committee.
Officers
The officers are servants of the committee and carry Treasurer
out its instructions. Committees have key officers,
usually the Chair, the Secretary and the Treasurer, A Treasurer will only be necessary if the committee
but larger committees may have additional appoint- is responsible for any financial matters. Treasurers
ments, for example, a Minutes Secretary. are expected to report on the financial position
quickly and precisely at any time by recording and
Chair summarising every transaction, so that it is easy to
see the current situation. At the end of the financial
Much of the work of the Chair may be done between year all financial transactions are summarised in an
meetings, but it is at the meetings when the Chair annual statement, a clear one-page summary.
is most visible, and has responsibility for ensuring
that the committee successfully completes its tasks.
It is vital for the Chair to be heard clearly during Quorum
meetings, so that all the committee can be involved.
It is unlikely that all committee members will be
Good Chairs delegate as much as possible, to ensure
able to attend all meetings. The rules usually state
active involvement of all members. The Chair also
the minimum number of members who must be
has the responsibility of preparing the next Chair
present for the meeting to be considered represent-
and must ensure that opportunities are provided
ative of members’ views and to have the authority
for the Vice Chair to develop.
to make decisions. This is called a quorum and is
usually one-third or one-half of the total voting
Secretary membership.
The Secretary is responsible for all the nonfinancial
papers and reports, for general planning and organ-
Committee Behaviour
isation (often in collaboration with the other offic-
ers) and for seeing that the committee’s work is Committees can be informal, but there are reasons
coordinated and nothing is forgotten. Good organi- for various formal behaviours. For example, the
sation, coordination and computing skills are rule that only one person speaks at a time and is
needed. There are a number of software pro- not interrupted is meant to ensure a fair hearing for
grammes (such as SharePoint – see Samson 2008) everyone. The Chair should not allow a vociferous
that can help with this work. few to dominate the meeting.
The rule of everyone speaking by addressing the Health promotion programmes and projects
meeting through the Chair helps to prevent a often require people from different organisations to
number of sub-discussions developing at the same work together; it is an established way of working
time. On the other hand, it may seem more natural in health promotion. Health promotion partner-
and helpful to address another committee member ships may be formally structured, with partners or
directly. Ultimately it is the job of the Chair to set a members at different levels from chief executives to
tone that encourages all members to participate field workers. There may be a written constitution
while keeping the meeting under control. and terms of reference, or arrangements may be
fairly informal. They may be long term, or set up
for a time-limited period to work on a specific
Understanding Conflict
project (see Scriven 2007 for a detailed examination
In itself, conflict is not bad. Conflict is inevitable at of partnership working).
times in any group because of differences in needs, The main reasons for setting up local partner-
objectives or values. The results of conflict will be ships are:
positive or negative depending on how it is handled. ● to harness a range of complementary skills and
Handled well, conflict can be a creative source of resources to work towards common goals
new ideas and can help a group to change and ● to avoid duplication and fragmentation of effort
develop. It can also strengthen the ability of group
● to avoid gaps in services or programmes.
members to work together. Conflict is badly handled
when it is either ignored so that negative feelings See Chapter 4, Fig. 4.1 for an overview of the
develop, or approached on a win/lose basis rather organisations working for public health.
than a compromise or a win/win position. Under-
take Exercise 9.3 to assess your conflict resolution Recent UK government health reforms have
style. created the opportunity for new styles of partner-
ships (Glasby & Dickenson 2009). Public health
work often involves health services and local
Working in Partnership authorities pooling their budgets for joint initia-
with Other Organisations tives and forming partnerships for planning,
commissioning and delivering services. These
See Chapter 4, section on primary care trusts for more new-style partnerships are genuine joint enterprises
on local strategic partnerships. with local authorities and others. Case study 9.1 is
EXERCISE 9.3 Your conflict resolution style

When confronted with conflict in a group you work in, which of these styles do you use?
Style Characteristic behaviour

Avoidance Ignores the problem; avoids raising the issue; denies that there is a problem
Accommodating Attempts to cooperate with everyone, even at the expense of not meeting personal or team
objectives
Win/lose Fights to win at any cost, even if it means alienating colleagues or causing the rest of the team to
fail in meeting their objectives
Compromising Suggests a compromise that would meet everyone’s basic needs and maintain good relationships
Problem-solving Openly confronts the problem and encourages everyone to face the disagreements and to express
fully their opinions and ideas. Searches for a new solution which meets everyone’s needs as
fully as possible
Review this chart with other members of groups you work in. Can you think of situations in which these different
approaches to conflict resolution were used? Discuss what worked and what did not. What could have been done
differently to improve the outcome?
What’s your conflict resolution style?
CASE STUDY 9.1 HEALTHY LIVING IN THE NEIGHBOURHOOD: A CASE STUDY ON COMMUNITY
DEVELOPMENT AND PARTNERSHIP WORKING
Healthy Living in the Neighbourhood was initiated by websites, blogs, video diaries, documentaries, music,
Featherstone High School and the South Southall animation, photo journalism, newsletters and more.
Extended Schools Partnership with support from Ealing The skills learnt in the various workshops have been
Healthy Schools and statutory and voluntary partners, made sustainable by teacher and peer training, and
such as Ealing City Learning Centre and Ealing Primary the work produced was shared with peers, family and
Care Trust. It is a schools and community partnership community via the schools’ and extended schools’
project designed to encourage peer education and websites. During the termly extended schools
community support in the healthy living changes being partnership meetings, any concerns were raised and
made in schools. Interactive learning and a multimedia the project was evaluated on an ongoing basis to
extravaganza allowed young people to share their determine the effect it’s impact on participating
learning experiences with the wider community and schools.
increase long-term uptake of healthy living messages.
The documentary
Rationale Three year 11 students from Featherstone High School
Schools in South Southall reacted quickly and were filmed in a 20-minute documentary, Good
creatively to government initiatives on healthy living. Attitude, following their efforts to change their health
Young people are well informed on healthy living but behaviour. They had 8 weeks to learn to eat well and
the uptake of healthier choice outside the school is exercise and to discover how changes might make a
slow. The general consensus among students is that big difference to what they may achieve in their lives.
the banning of certain foods and changes to their This documentary was the focus of the overall DVD
school lunch menus have been top down. Schools resource produced by and for the schools. The DVD is
have recognised that the impetus for change rests provided to all primary and high schools in Ealing and
with the students, and that their decision to embrace includes lesson plans for Key Stage 3 that relates to
healthy living will break down barriers of resistance at the Ealing Scheme of Work for personal, social and
home with their families. health education (PSHE) and Healthy Schools
Process programme. In addition, the DVD includes the Family
Healthy Living in the Neighbourhood endeavoured to Recipe Book produced by the partnership and used in
cater to needs of the nine schools in an extended parent cookery classes, a selection of the work
schools partnership, through devising workshops in produced over the course of the project and other
both healthy living and media/IT/creative technologies. materials requested by participating schools.
Key steps were: Outcomes
■ Identification of schools to participate from the
■ Featherstone High School students were trained in
extended schools partnership. blogging and podcasting during a summer
■ Catering to individual schools’ needs through
workshop and recorded their experiences on a
consultation. healthy living plan throughout the Autumn term.
■ Developing and delivering after school, in the
Teacher training was implemented during a 2-week
holidays and during noncurriculum time a series of period where the teaching timetable is disbanded
participatory multimedia workshops for young and students participate in a range of outings,
people on health themes. educational visits and educational workshops.
■ Implementing training for staff on multimedia
■ ‘Healthy Living at Three Bridges Primary’: a year 5
skills, thereby building skills in the community. class at Three Bridges Primary School was trained
■ Filming a documentary of year 11 students’ healthy
in video making at the Ealing City Learning Centre
living efforts. and they used their skills to produce a short film,
■ Compiling a DVD documenting the work of the
produced by South Southall Extended Schools. The
project. class shares their healthy living experiences
Workshops and training creatively with the school and wider community.
Students explored a broad range of healthy living ■ ‘We Like to Be Healthy’: a song performed and
issues and were given the opportunity to create written by the children at Greenfields Children’s
Continued
CASE STUDY 9.1 HEALTHY LIVING IN THE NEIGHBOURHOOD: A CASE STUDY ON COMMUNITY
DEVELOPMENT AND PARTNERSHIP WORKING – cont’d
Centre produced by South Southall Extended scale, before realising the practicalities and
Schools in partnership with Featherstone High limitations of time, resources and manpower.
School. ■ Community partnership projects can take longer
■ A year 5 class at Featherstone Primary was trained than anticipated. Building trust and relationships
in blogging during a holiday activity workshop and and getting schools on board takes time.
recorded their experiences while on a healthy ■ Cater for schools expressed needs at all times.
living plan. Teacher training and peer training were Schools need to see that their involvement is
implemented during the Autumn term. relevant to their priorities.
■ The holiday programme of activities focused on the ■ A community partnership project needs strong
healthy living theme and, open to all pupils from coordination and leadership to drive the project
the South Southall Extended Schools Partnership, forward. All partners need to be committed to
included music production, journalism, design and the initiatives, carrying out the actions and
photography, blogging and podcasting. ensuring skills learnt are sustained and not
Points learnt from Healthy Living forgotten.
in the Neighbourhood experience The South Southall Extended Schools Partnership
■ Keep ideas realistic and ensure projects are small includes Clifton Primary, Dairy Meadow Primary,
scale. Schools have increasing workloads and a Featherstone High School, Featherstone Primary,
growing number of priorities, therefore it is Greenfields Childrens Centre, Havelock Primary,
essential to work on achievable partnership St Anselm’s Primary, Three Bridges Primary, Wolf
projects. Initial ideas were for projects on a larger Fields Primary.
(Case study produced by Natalie Shepping, South Southall Extended Schools Coordinator, London.)
an interesting example of partnership working. duplication and sharing knowledge of mutual

Neighbourhood renewal strategies are also leading interest. Members meet and talk, but they do not
the way in breaking down organisational barriers actually work together. Networking has the lowest
and engaging members of communities in partner- degree of involvement between organisations.
ship arrangements.
See Chapter 4, sections on primary care trusts and local Cooperating
authorities, for information on health action zones and
Cooperating means that member agencies help
neighbourhood renewal strategies. Also see Chapter 6,
each other in ways that are compatible with their
section on local strategies and initiatives.
own goals. They meet, talk and agree to participate
In general, partnerships can take different forms, in each other’s work when this is helpful for their
and vary in terms of how closely members work own work plans. For example, in an accident pre-
together. It is useful to think of three main ways of vention partnership, people who work in the acci-
working, spanning a range of degrees of involve- dent and emergency (A&E) department of a hospital
ment between partners: may cooperate with a local alcohol advisory service
(a voluntary organisation) to ensure that patients
Networking – Cooperating – Joint working
brought in with a drink problem know that they can
go to the alcohol agency for help. This cooperation
helps the alcohol agency to reach needy potential
Networking clients, and helps the A&E department to fulfill its
Networking means coming together with other role of helping patients with longer term health
people from different agencies, and exchanging needs. This way of working in partnership means
information and ideas on activities and plans. This a moderate degree of involvement between
is useful for coordinating activities, avoiding partners.
Joint working ● Someone acceptable to all partners needs to

take responsibility for running the partnership
Joint working means coming together to agree a (for example setting up, chairing and servicing
mutually acceptable plan, and working together to meetings) and coordinating action. A full-time
carry it out. This necessitates a high degree of coordinator can be extremely helpful.
involvement between partners. For example, the
● There must be mutual respect between
police, the probation service, road safety officers
partners; all partners need to feel that others
from the local authority and a local alcohol advi-
value their input.
sory service may all work together to plan, imple-
● Working relationships need to be characterised
ment and evaluate a joint programme of work to
by openness and trust. Partners need to
reduce drink-driving levels.
recognise and resolve potential areas of
Partnerships can operate in one, two or all of
conflict.
these ways. Sometimes joint working is thought to
be the most effective, but networking and cooperat- ● There must be an agreed framework for
ing can be useful when it is not always feasible or reviewing the partnership, changing the way of
worthwhile to aim for full joint working. working if necessary, and even bringing it to an
end if it has outlived its usefulness or is
unproductive.
Factors for Successful Partnership
● Awareness and understanding of partner
Working
organisations should be promoted through
Successful partnerships are usually the result of joint training programmes and incentives to
investing a considerable amount of resources, skill work across organisational boundaries.
and time to enable members to work well together ● Partnership arrangements need to be regularly
(Markwell et al 2003). The Verona Benchmark, a reviewed and adapted to reflect the lessons
partnership benchmarking tool, is useful in inform- learned from experience.
ing and assessing partnership processes and outputs
(see the special edition of Promotion and Education See also earlier sections in this chapter on coordination
2000 7(2), for a series of articles on Verona Bench- and teamwork.
marking and specifically Watson et al 2000). Key
factors for success are:
● All partners need to be working towards a Potential Difficulties with
shared vision of what the partnership should Partnership Working
achieve, with an agenda and goals to which all Partnership working can result in many difficulties.
partners concur. Major problems are:
● There must be an agreed approach. All partners
● Organisational change, which blights long-term
need to feel a sense of ownership with no one
commitment and planning.
partner dominating.
● Competition between member agencies for
● Commitment from the highest level of member
funding, for example between different
organisations is vital to ensure that belonging
voluntary organisations who are seeking
to the partnership fits in with the organisation’s
funding from the same source.
strategic aims and that there will be
● Lack of resources, both money and person-
management support for input of time and
other resources. power.
● Lack of top-level commitment from members of
● There must be commitment of sufficient time
and resources and realistic expectations. the partnership.
Partnership working is time-consuming, and it ● Domination by an individual.
may take months or years to develop a shared ● An imbalance of input from different agencies,
understanding and joint plans, or achieve which can lead to resentment and issues about
outcomes from joint health promotion ownership of joint activities and who takes the
activities. There must, however, be credit for success.
demonstrable achievements, otherwise the ● Professional jealousy and unwillingness to
partnership will be regarded as ineffective. share expertise and information.
● Differences between agencies and individuals use them and the quality of your professional
in terms of different goals and values; different relationships.
organisational cultures and ways of working; ■ Health promotion often involves different
different levels of expertise and experience. professionals and disciplines working together; there
It is worth bearing in mind that not all partnerships is a range of ways in which you can encourage
are successful. Many fade out or are wound up. good teamwork and coordination.
Partnership working is not an end in itself; it is a ■ For effective meetings and committee work, you
means to an end, and there are circumstances where require knowledge of and competencies in the roles
the end is better achieved by an organisation and responsibilities of committee members.
working alone. ■ Health partnerships between two or more
organisations work at varying levels of involvement
with each other, from networking at a local or
PRACTICE POINTS national level to full joint working and from local
■ A key aspect of successfully implemented health partnerships to strategic partnership. Think about
promotion programmes is how well you and other the many factors that contribute to success, and the
health promoters work together. potential pitfalls to avoid.
■ You need to think about how you communicate
with colleagues: the channels you use, how well you
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131
PART 3
Developing competence
in health promotion
Part Contents
10. Fundamentals of communication 133
11. Using communication tools in health promotion practice 147
12. Educating for health 163
13. Working with groups 177
14. Enabling healthier living 191
15. Working with communities 207
16. Influencing and implementing policy 223
Part Summary
Part 3 aims to provide you with guidance in how to the links with promoting self-esteem and assertiveness.
assess, develop and improve your competencies in Four basic communication skills are identified and
health promotion. guidance provided on how to improve them. Commu-
Competencies are the combinations of knowledge, nication and language barriers, nonverbal commun
attitudes and skills needed to plan, implement and ication and written communication are discussed.
evaluate health promotion activities in a range of set- In Chapter 11 some principles governing the choice
tings. You will also need to develop other core compe- of communication tools in health promotion are
tencies of health promotion, such as communicating covered. The advantages and limitations of a variety of
and educating, marketing and publicising, facilitating teaching and learning resources are considered and
and networking and influencing policy and practice. guidance provided on how to produce and use displays,
Some chapters of Part 3 will be more important to some written materials and statistical information. The
professions or disciplines than others. So you may wish use of mass media in health promotion is explored,
to start by studying the chapters most relevant to you, including practical help about working with the local
rather than going through them in sequence. Cross- press, radio and television. There is a section included
referencing is provided to help you to identify which on the use of information technology in health
sections of other chapters may also be relevant to your promotion.
particular needs. In Chapter 12 the principles of adult learning are
In Chapter 10 the fundamentals of communication outlined. How you can enable people to learn and
are addressed, including establishing relationships, and evaluate the learning outcome is described, along with
guidelines on giving talks, and on patient health In Chapter 15 the focus is community-based work
education. in health promotion, including community participa-
Chapter 13 covers the health promotion competen- tion, community development and community health
cies required to work effectively with groups, covering projects.
how to lead groups and how to understand group Chapter 16 is about how local and national policies,
behaviour. programmes, plans and strategies are made and how
Chapter 14 concentrates on how to enable people they can be influenced. The methods that health pro-
to change their behaviour towards healthier living, moters can use to challenge health damaging policies,
including information on models of the process of and develop, implement and evaluate health promotion
changing health-related behaviour. Strategies that can policies are outlined, including sections on the princi-
be used, such as working with a client’s own motivation ples and the planning of campaigns.
and counselling to help people to make decisions are
discussed alongside the principles that help with using
these approaches.
133
Chapter 10
Fundamentals of communication
Summary
Chapter Contents
This chapter starts with an exploration of client/
Exploring relationships with clients 134 professional relationships and a discussion of the
links between self-esteem, self-confidence and
Self-esteem, self-confidence and
communication, accompanied by a case study
communication 135
on relationship skills. Discussion on four basic
Listening 136 communication skills (listening, helping people to talk,
asking questions and getting feedback) is followed by
Enabling people to talk 137
consideration of communication and language barriers
Asking questions and getting feedback 138 and nonverbal communication. The chapter ends with
a section on written communication. Exercises are
Communication barriers 140
provided on overcoming communication barriers and
Overcoming language barriers 141 on each basic communication skill.
Nonverbal communication 141
Written communication 145
See also Chapter 12, which discusses communication

and education between health promoters and patients.
Effective communication in a range of contexts is

fundamental to success in health promotion (See
Corcoran 2007 for details on communicating for
health promotion in different contexts). Communi-
cation should be clear, unambiguous and without
distortion of the message.
This chapter discusses some fundamentals of
relationships with clients, communication barriers
and basic communication skills (see Hartley 2004
for an interesting assessment of possible verbal and
nonverbal communication barriers). These skills
will often be applied in one-to-one situations,
though they may apply when working with groups,
running workshops, as well as in more formal
situations.
than yours’ is judgemental; ‘My standards are

Exploring Relationships
different from yours’ is not.
with Clients
Health promoters should ask themselves some fun- Autonomy or Dependency?

damental (and possibly uncomfortable) questions.
For example, what is your basic attitude towards There are a number of ways in which you can help
the people to whom your health promotion is clients to take more control over their health.
directed? Do you accept them on their own terms Autonomy can be enabled by:
or do you judge them by your own standards? Do ● Encouraging people to think things through
you aim to enable people to be independent, make and make their own health decisions, resisting
their own decisions, take control of their health and the urge to dominate the decision-making
solve their own health problems? Or are you actu- process.
ally encouraging dependency, solving their prob- ● Respecting any unusual ideas they may have.
lems for them and thereby decreasing their own Autonomy can be hindered if:
ability and confidence to take responsibility for
● You impose your own solution on your clients’
their health? It may be useful to work through the
health problems.
following questions, thinking about how you relate
● You tell them what to do because they are
to your clients.
taking too long to think it through for
Accepting or Judging? themselves.
● You tell them that their ideas are not good and
Accepting people is demonstrated by:
won’t work, without giving an adequate
● Recognising that clients knowledge and beliefs
explanation or an opportunity to try them out.
emerge from their life experience, whereas your
own have been modified and extended by An aim which is compatible with health promotion
professional education and experience. principles and ethical practice is to work towards
as much autonomy as possible. By doing this, you
● Understanding your own knowledge, beliefs,
are helping people to increase control over their
values and standards.
own health. Obviously, there are times when
● Understanding your clients’ knowledge, beliefs,
working towards autonomy may not be feasible.
values and standards from their point of view. For example, it is more demanding of resources and
● Recognising that you and your clients may clients may be dependent on a health promoter
differ in your knowledge, beliefs, values and because they are ill, or uninformed or likely to put
standards. themselves or other people in danger.
● Recognising that these differences do not suggest
that you, the professional health promoter, are a
A Partnership or a One-Way Process?
person of greater worth than your clients.
Judging people is demonstrated by: Do you think of yourself as working in partnership
with people in pursuit of health promotion aims, or
● Equating people’s intrinsic worth with their
do you see health promotion as your sole responsi-
knowledge, beliefs, values, standards and
bility, with yourself as the expert?
behaviour. For example, saying that someone
A partnership means:
who drinks beyond safe limits is foolish both
judges and condemns that person, and takes no ● There is an atmosphere of trust and openness
account of life experience and cultural between yourself and your clients, so that they
background. Saying that drinking beyond safe are not intimidated.
levels may damage health does not judge the ● You ask people for their views and opinions,
person in the same way. which you accept and respect even if you
● Ranking knowledge and behaviour. For disagree with them.
example, ‘I’m the expert so I know better than ● You tell people when you learn something
you’ is judgemental; ‘I know a considerable from them.
amount about this particular health issue’ is a ● You use informal, participative methods when
statement of fact. ‘My standards are higher you are involved in health promotion, drawing
Chapter 10 Fundamentals of communication 135
on the experience and knowledge that clients (Freshwater 2003). This should seek to build on
bring with them. people’s existing knowledge and experience, move
● You encourage clients to share their knowledge them towards autonomy, empower them to take
and experience with each other. People do this responsibility for their health and help them to feel
all the time, of course (for example, knowledge positive about themselves.
and experience are discussed between
participants on a smoking cessation programme
and parents in a baby clinic), but do you Self-Esteem, Self-Confidence
actively foster and encourage this? and Communication
A one-way process means:
● You do not encourage clients to ask questions The ability to communicate is closely linked to how
and discuss health needs. people feel about themselves. People with a low
● You imply that you do not expect to learn
sense of self-esteem tend to be over-critical of them-
anything from your clients (and if you do learn, selves and to underestimate their abilities (Allen
you don’t say so). et al 2002). This lack of self-confidence is reflected
in their ability to communicate. For example, they
● You do not find out people’s health knowledge
may lack assertiveness and thus may either fail to
and experience.
speak up for themselves or react with inappropriate
● You do not encourage people to learn from
anger and even violence.
each other. Assertiveness means saying what you think and
● You use formal health promotion approaches asking for what you want openly, clearly and hon-
rather than participative methods. estly. It does not mean being aggressive or bullying,
but it is in contrast with hiding what you really feel,
Clients’ Feelings – Positive saying what you don’t really mean or trying to
or Negative? manipulate people into doing what you want.
A change in people’s health knowledge, attitudes Assertiveness helps people to create win–win
and actions will be helped if they feel good about situations (situations where everyone involved
themselves. It will rarely be helped if they are full feels that they have achieved a reasonable outcome)
of self-doubt, anxiety or guilt. through direct and open communication and
Clients will feel better about themselves if: through avoiding aggressive behaviour (which can
result in win–lose situations, where one party feels
● You praise their progress, achievements,
that they have won and the other party feels they
strengths and efforts, however small.
have lost) or manipulation (lose–lose situations,
● The consequences of unhealthy behaviour such
where, for example, one party in a negotiation
as smoking are discussed without implying walks out). It builds the self-esteem of all concerned.
that the behaviour is morally bad. Successful negotiation is a good example of how
● Time is spent exploring how to overcome assertiveness can work. In a successful negotiation
difficulties, such as practical strategies to help a both parties are more likely to come away with the
client stop smoking. This will help to minimise following thoughts:
feelings of helplessness.
● This is an agreement which, while not ideal, is
Clients will feel bad about themselves if: good enough for both of us to support.
● You ignore their strengths and concentrate on ● Both of us made some compromises and
their weaknesses. sacrifices.
● You ignore or belittle their efforts. ● We will be able to have successful negotiations
● You attempt to motivate them by raising guilt with each other in future.
and anxiety (such as ‘if you don’t stop smoking Many clients with low self-esteem will need to learn
you’ll damage your baby’). how to feel better about themselves before they can
To sum up, the health promotion aim of enabling communicate effectively with health promoters
people to take control over and improve their health (Emler 2001). Although Emler (2001) reports that
is best achieved by unconditional positive regard most programmes to raise self-esteem had not been
and working in nonjudgemental partnerships successful, people with low self-esteem require key
life skills in order to take control of their health. ● Listen and acknowledge that you have these
These skills include how to communicate and relate feelings too.
to others in a morally responsible manner, and with ● Label the feelings.
respect and sensitivity towards the needs and views ● Set limits for the interaction while exploring
of others. Unfortunately, the nonstatutory status strategies to solve the problem.
and the time allotted to personal and social educa-
tion in schools may be insufficient for young people
to develop these skills (King 2005). Listening
Case study 10.1 illustrates how parents can learn
to develop the self-esteem of their children and As a health promoter, you need to develop skills of
ensure that their children understand the rights of effective listening so that you can help people to
other people. While the case study refers to parents talk and identify their needs and feelings.
and children, the same principles can be used by Listening is an active process. It is not the same
health promoters with their clients. as merely hearing words. It involves a conscious
So, when working with clients with low self- effort to listen to words, to the way they are said,
esteem, you may find it helpful to: to be aware of the feelings shown and of attempts
● Be aware of the client’s feelings. to hide feelings. It means taking note of the non
● Recognise the opportunity to help the client to verbal communication as well as the spoken words.
learn about how to handle difficult feelings. The listener needs to concentrate on giving the
CASE STUDY 10.1 RELATING SKILLS – LORRAINE AND JACK

Lorraine is late for work and tries to coax her Jack: (nodding) ‘Yes’.
3-year-old son, Jack, into his coat so that she can Lorraine: ‘I feel a bit sad too. It’s OK for you to
take him to nursery school. Jack starts to cry. Lorraine cry.’ (Hugs him while he cries.) ‘I know what.
hugs him but tells him that he’s got to go to school. Let’s think about what to do on Saturday when
She is at a loss about what else to do, and when she I don’t have to go to work and you don’t have
reaches nursery school Jack is still crying. One of the to go to school. Can you think of anything
nursery nurses notices his distress and manages to special you would like to do on Saturday?’
calm him. When Jack has recovered, the nurse talks to Jack: ‘Can we go to the park and feed the ducks?’
Lorraine about what she’s learnt from a book by Lorraine: ‘Yes. That would be great.’
Gottman & Declaire (1997) and about five steps to Jack: ‘Can Nick come too?’
better parenting. Lorraine learns that children whose Lorraine: ‘Perhaps. We’ll have to ask his Mum. But
parents consistently practise these five steps have right now it’s time to get going.’
better physical health and score higher academically Jack: ‘OK.’
than children whose parents do not. They also relate Lorraine has gone through five steps:
better with friends, have fewer behaviour problems 1. She becomes aware of Jack’s feelings.
and are less prone to acts of violence. 2. She recognises the opportunity for helping Jack to
A week later in a similar situation Lorraine tries learn about how to handle emotions.
out what the nurse suggested. She starts in the same 3. She listens to Jack, tries to understand his
way as before, by empathising with Jack, but this feelings and lets him know it is OK to feel bad
time she goes further and provides him with guidance and upset sometimes, and that she has these
on what to do with his uncomfortable feelings. The feelings too.
conversation goes something like this: 4. She helps Jack to find the words to label the
Jack: ‘It’s not fair. I don’t want to go to school’. emotion he is having.
(Starts to cry.) 5. She sets limits while exploring strategies to solve
Lorraine: ‘Come here Jack’. (Takes him on her knee.) the problem.
‘I’m sorry but we can’t stay at home. I have lots
to do at work. Does that make you feel sad?’
EXERCISE 10.1 Learning to listen

Client Health Promoter
Work in groups of three to six people. Appoint someone
What I say What I hear
as a timekeeper.
1. Person A speaks for 2 minutes, without
interruption, on a subject of her choice to do
with work or other interests (for example, sensible
What I mean or feel What I understand
drinking guidelines, keeping fit and active, pets,
holidays). Everyone else in the group listens,
Fig. 10.1 The listening process. (Figure adapted from Rollnick without interrupting or taking notes.
et al 1999). 2. Person B repeats as much as she can remember,
without anyone else interrupting. Person B may
not:
speaker full attention, being on the same level phys- – add anything extra to what A said
ically as the speaker and adopting a nonthreatening – give interpretations (for example ‘It’s obvious
posture. from what she said that …’)
Fig. 10.1 illustrates that active listening involves – give comments (for example ‘She’s just like
searching for an understanding of the underlying me …’).
meaning behind the words used by the client. It 3. A, and the rest of the group, identify what was
shows how the meaning conveyed by the client can inaccurate, forgotten or added.
become distorted if the client cannot express exactly 4. Repeat, with a different topic, until everyone has
what he or she means. At the second step it shows had a turn at being A and B.
that the health promoter may not hear what is being 5. Discuss the following questions:
said. Third, the health promoter may hear the – What helped me to listen?
words accurately, but interpret them in a different – What helped me to remember?
way from that which the client intended. – What hindered my listening?
When listening, it is easy to allow attention to – What hindered my remembering?
wander. Some of the things you may find yourself – What did I learn about myself as a listener?
doing instead of listening are planning what to say
next, thinking about a similar experience, interrupt-
ing, agreeing or disagreeing, judging, blaming or
criticising, interpreting what the speaker says, Giving an invitation to talk
thinking about the next job to be done or just plain
daydreaming. To get someone started it may be helpful to give out
The task of a listener is to encourage people to a specific invitation to talk. Examples are:
talk about their situation unhurriedly and without ‘You don’t seem to be your usual self today. Is
interruption, enabling them to express their feel- something on your mind?’
ings, views and opinions, and to explore their ‘Can we talk some more about that matter you
knowledge, values and attitudes. This reinforces raised briefly at yesterday’s meeting?’
the speakers’ responsibility for themselves and is ‘You look worried – are you?’
essential for helping them towards greater respon-
sibility for their own health choices. To practise Giving attention
listening skills work on Exercise 10.1.
This means listening closely to what is being said,
and being fully aware of all the channels of com-
Enabling People to Talk munication, including nonverbal behaviour. It
requires effort and concentration to listen hard and
The main task of the listener is to encourage and give full, undivided attention.
enable someone to talk. There are several useful
techniques, as follows. Encouraging
See also Chapter 14, section on strategies for decision This means making the occasional intervention to
making, which discusses counselling skills. encourage someone to carry on talking. It tells the
speaker that you really are listening, and want to Exercise 10.2 gives you the opportunity to prac-
hear more. Such interventions include noises like tise skills in enabling people to talk.
‘mm mm’, words such as ‘yes …’ and short phrases
such as ‘I see …’ or ‘And then …?’ or ‘Go on …’.
Another useful intervention is the repetition of Asking Questions and
a key word which the speaker has just used. For Getting Feedback
example, if the speaker says ‘I am worried by
my weight gain’, you could repeat the word Skilful questioning will help people to give clear,
‘weight …?’ full and honest replies. It is useful to distinguish
different types of questions.
Paraphrasing
Types of Questions
This means responding to the speaker using your
own words to state the essence of what the speaker Closed questions are questions that require short,
has been saying. Use key words and phrases, for factual answers, often only one word. Examples are:
example, ‘So you’re not sure whether to have the ‘What is your name?’
baby vaccinated or not?’ or ‘So you are feeling ‘Is this address correct?’
unhappy because you are overweight and being ‘Are you able to see me again next Tuesday?’
unhappy triggers overeating?’
Closed questions are appropriate when brief,
factual information is required. They are not appro-
Reflecting feelings priate when the aim is to encourage talking at more
length. So ‘Did you get on OK with your healthy
This involves mirroring back to the speaker, in
eating plan last week?’, which could be answered
verbal statements, the feeling he is communicating.
by ‘yes’ or ‘no’, is not the best way to encourage
To do this it helps to listen for words about feelings,
people to express their experiences of trying to
and to observe body language. Examples are ‘You
change what they eat. A better question would be
seem pleased’ or ‘You are obviously upset about
‘How did you get on with your healthy eating plan
this’.
last week?’ This is an open question.
Open questions give an opportunity for full
Reflecting meanings answers. Examples are:
This means joining feelings and content in one suc- ‘How did you get on at the meeting yesterday?’
cinct response, to get a reflection of meaning: ‘What situations do you feel trigger
‘You feel … because …’ overeating?’
‘You are … because …’ ‘What do you think about trying to take a short
brisk walk every day?’
‘You’re … about …’
Note that words like ‘how’, ‘what’, ‘feel’ and ‘think’
For example:
are useful for encouraging a full response.
‘You feel pleased about your progress.’ Biased questions indicate the answer the ques-
‘You’re depressed because your children have tioner wants to hear, or expects to hear. In other
grown up and left home.’ words, biased questions are likely to bias the
‘You’re angry about all the rubbish left on the response by leading the person who answers in a
streets of your neighbourhood.’ particular direction. Examples are:
‘You’re feeling better today, aren’t you?’ (This is
Summing up biased because it would be easier to answer
‘yes’ than ‘no’.)
This is a brief re-statement of the main content and
feelings which have been expressed throughout a ‘You have been doing what we discussed last
conversation. Check back with the speaker to ensure time, haven’t you?’
that the statement is accurate. For example, say ‘It ‘Surely you aren’t going to do that, are you?’
seems to me that the main things you’ve been Multiple questions contain more than one ques-
saying are … Does that cover it?’ tion. Multiple questions are likely to confuse,
EXERCISE 10.2 Helping people to talk

Work in pairs. Each person chooses a topic she feels (‘yes …’) and nondirective comments (‘I see …’) or repeats
strongly about (which might be a personal experience or key words. Swap roles. Then spend 5 minutes discussing
topic of general concern such as sex education, traffic these questions:
jams, cuts in the health service or violence on television). When you were listening:
Stay with the same topic for all three stages of the ■ What sort of interventions did you make?
exercise. (The whole exercise takes about 45 minutes.) ■ How did you feel about making them?
When you were speaking:
Stage 1. Giving attention
■ What interventions did you notice?
One person speaks for 2 minutes, and the other listens, ■ Did you find them helpful?
giving only nonverbal feedback. Then swap roles. After
Stage 3. Paraphrasing, reflecting back
both of you have had your turn, spend 10 minutes
and summing up
discussing these questions:
When you were listening: One person speaks for 5 minutes and the other listens.
■ What did you find difficult about listening? The listener makes encouraging interventions as in Stage
■ Did your mind wander? 2, but also paraphrases, reflects feelings and reflects
■ Did you maintain eye contact? meaning when she feels it is appropriate. At the end, she
■ What did you notice about the speaker’s nonverbal makes a brief statement summing up the main content
communication? and feelings of the speaker, checking with the speaker
When you were speaking: that her summing up is accurate. Exchange roles. Then
■ What did the listener do which helped you to talk? spend 10 minutes discussing these questions:
■ Did the listener do anything that made it difficult When you were listening:
for you to talk? ■ What sort of interventions did you make?
■ How did you feel about making them?
Stage 2. Encouraging
When you were speaking:
One person speaks for 2 minutes. The other listens and ■ What interventions did you notice?
gives encouraging interventions (such as ‘mm mm’), words ■ Did you find them helpful?
because the listener will not know which question Getting Feedback
to answer, and probably will not remember all of
them. Examples are: After people have been given some information, or
have been taught a skill, it is very important to
‘Is this a serious problem for you – when did it check to make sure that they really have under-
start?’ stood what was said, and remembered it, or mas-
‘Does your store have a policy on promoting tered the skill. This is especially important when
healthy foods – do you stock low-alcohol there is any doubt about how much has been under-
drinks and did you promote displays of stood, perhaps because, for example, someone is in
low-fat products during the special a state of anxiety or has a limited command of
campaign last September?’ English. There are two key points to note about
‘What are you going to do to get the Council to getting feedback.
take all this rubbish away and are you going 1. It is your responsibility to ensure that the communi-
to get more bottle banks and newspaper cation has been received and understood. It is not the
recycling bins?’ fault of the listener if they tried but did not
understand.
‘Are you sure you know what to do or would
It can be helpful to ask a question in a way which
you like me to explain it again?’
shows that it is your responsibility as a health pro-
Exercise 10.3 is an opportunity to practise asking moter to be understood. For example, say ‘May I
appropriate questions. check to make sure I’ve covered everything – could
communication barriers exist is the necessary first

EXERCISE 10.3 Asking questions
stage before work can begin on tackling the prob-
Work in groups of about 10 people. lems. There are no easy solutions, but increased
Decide on a topic on which it is easy to think of awareness and skill can go a long way towards
questions – such as pets, holidays, my job, my family. improvement.
■ Person A volunteers to answer questions. Common communication barriers may be cate-
■ Person B observes the length of A’s response to gorised into six types.
questions.
■ Person C observes A’s nonverbal behaviour (body
language). 1. Social and cultural gaps
■ Everyone else has the task of asking questions. A number of factors can cause gaps, among
First, everyone in turn asks a closed question on the which are:
topic. ● different ethnic or social groups, which may be
Second, everyone in turn asks an open question on apparent in dress, language or accent
the topic. ● different cultural or religious beliefs, for
Third, everyone asks biased questions on the topic. example about hygiene, nutrition or
After these three rounds of questions: contraception
■ Person A says how she felt about having to
● different values, reflected in a different
answer the three different kinds of questions
emphasis on the importance of health issues
(e.g. clear? muddled? irritated? angry? confused?).
● different gender or sexual orientation, reflected
■ Person B says what she observed about the length
of A’s responses to the three kinds of questions. in different approaches, interests or values.
■ Person C says what she observed about A’s
nonverbal behaviour when answering the three 2. Limited receptiveness
different kinds of questions.
Discuss the application of what you found out to You might want to communicate, but the reverse is
your work. not always true: people might not want to be com-
municated with. They may be unreceptive for many
reasons, including:
● learning difficulty or confusion
● illness, tiredness or pain
● emotional distress
you just recap what you understand so far?’ Avoid
questions such as ‘Let’s see if you’ve learnt it yet, ● being too busy, distracted or preoccupied
could you show me?’ or ‘I don’t think you’ve ● not valuing themselves, or not believing that
totally understood, tell me what you think the main their health is important.
points are’.
2. Ask open questions. Closed questions such as
‘Do you understand?’ are not an adequate way of 3. Negative attitude to the health promoter
getting feedback. People may answer ‘yes’ because Some people may be resistant to you, even before
they are embarrassed, intimidated or afraid of you have met. This may be caused by:
making a fool of themselves by admitting that they
● previous negative experiences
do not understand. Or they might just want to draw
● lack of trust in anyone seen as an authority
the conversation to a quick conclusion. Ask open
questions, such as ‘Could you please tell me what figure
you’re going to do …’ ● lack of credibility of the health promoter
(perhaps you set a poor example of good health
yourself?)
Communication Barriers ● perceiving you as a threat, coming to criticise
or pass judgement
As a health promoter you may encounter numerous ● thinking that they already have the knowledge
difficulties in communicating. Recognising that and skills
● believing that advice will be given which they

EXERCISE 10.4 Identifying communication
cannot comply with because of financial or barriers
social constraints, or being asked to change a
lifestyle or behaviour that they enjoy This exercise can be done alone, but it is best carried
● not wishing to confront issues such as personal out in pairs or small groups so that ideas can be shared.
health problems, or the need to change policies Consider the six types of communication barriers
and practices at an organizational level. discussed.
1. How many of them can you identify in your own
health promotion practice or experience?
4. Limited understanding and memory 2. What other communication barriers can you add
to this list?
There may be difficulties because people: 3. What communication barriers cause you the most
● understand and/or speak little or no English problems?
● have limited education or learning difficulties, 4. What suggestions can you make for helping to
and may be unable to read and write break down communication barriers? (Share
● are being confronted with technical words, examples from your own experience and make
jargon or medical terminology that they do not additional suggestions.)
understand
● have poor or failing memories and cannot
remember what was discussed previously.
5. Insufficient emphasis by the health Overcoming Language Barriers

promoter
Communication may fail because you do not give Language is only one facet of the gulf that may exist
it sufficient time and attention. The reasons may be: between people of different ethnic backgrounds.
The root of communication problems may be
● communication was given a low priority in
racism. This is a huge topic, largely outside the
basic training, so it is given low priority in
scope of this book, but all health promoters should
practice
take part in racism awareness training when
● lack of confidence, skills and knowledge, which working with people from different ethnic groups
may be the result of inadequate training (see Robinson 2002 for more about communication
● being too busy with other things, and unable to in multiethnic societies)
find the time However, when we focus solely on the question
● managers not being supportive about time of language barriers, learning a few essential words
spent on health promotion and phrases in the other person’s language may
● reluctance to demystify and share help. Help with learning the language may be avail-
professionally acquired health knowledge. able from multicultural education centres run by
local education authorities.
When faced with a language barrier, there are
6. Contradictory messages some useful guidelines which you can follow to
Communication barriers are erected when people help someone with limited English to understand
receive different messages from different people. what is being said. See Box 10.1 and Exercise 10.5.
For example:
● different health professionals give different
Nonverbal Communication
advice
● family, friends or neighbours contradict health Nonverbal communication (NVC) includes the
promoters ways people communicate other than by the spoken
● health advice changes as evidence is updated. word. It is sometimes called body language. The
In order to identify communication barriers in your main categories of nonverbal communication are as
work undertake Exercise 10.4. follows.
BOX 10.1 Guidelines for health promotion communication with individuals or small groups
who speak little English
If you are engaging in health promotion with individuals 4. Say things in a logical sequence: the sequence in
of small groups who speak little English, you should which they are going to happen. So say ‘Eat first,
attempt to find out whether a translator could be then take the tablet’ rather than ‘Take the tablet
present. If you use a translator, allocate more time for after you eat’. If the listener does not pick up the
the session. Give information concisely and in stages; word ‘after’ correctly, he will take the tablet first,
this will allow time for the translator to explain to the because that is the order in which he heard the
clients and to translate back information from the instruction.
clients. Using children or relatives to translate 5. Be careful of idioms. Being ‘fed up’, ‘popping out’ and
information to clients can be less reliable than using ‘spending a penny’ may be totally incomprehensible.
trained translators. 6. Do not attempt to speak pidgin English. It does not
If you do not have a translator, the following points help people to learn correct English, and sounds
may be helpful: patronising.
1. Speak clearly and slowly, and resist raising your 7. Use pictures, mime and simple written instructions,
voice in an effort to be understood. which may be read by relatives or friends who
2. Repeat a sentence if you have not been understood understand written English. Be careful of symbols
using the same words. If you use different words on written material; ticks and crosses, for example,
you are likely to cause more confusion by might not convey what you intend.
introducing even more words which are not 8. Check to ensure that you have been understood, but
understood. avoid asking closed questions that require a
3. Keep it simple. Use simple words and sentences. one-word answer such as ‘Do you understand?’ A
Use active forms of verbs rather than passive reply of ‘Yes’ is no guarantee that your client really
forms, so say ‘The nurse will see you’ rather than has understood.
‘You will be seen by the nurse’. Do not try to cover
too much information, and stick to one topic at a See section on asking questions and getting feedback
time. earlier in this chapter.
EXERCISE 10.5 Overcoming language barriers

The following five extracts come from the district nurse’s … Oh dear … (louder) … DOCTOR SAYS YOU
side of a conversation with a patient whose English is TAKE TABLET THREE TIMES A DAY’.
very limited. ‘I’ll leave this list of foods for you. There are ticks
‘Hello – Oh, we are looking brighter today!’ and crosses on it to show you what you can
‘Have you been visited by the doctor today yet? eat and what you should not eat. Do you
Did he give you a new prescription?’ understand? Your son can read English,
‘I’ll see about your insulin after I’ve seen how your can’t he?’
leg’s getting on’. Using the guidelines in points 1–8 in Box 10.1:
‘The doctor says you should take one of these ■ Identify what is unhelpful about the way the
tablets three times a day … I don’t think you district nurse speaks to the patient.
understand – I’ll say that again … We want you ■ Suggest better alternatives.
to take one of these tablets three times a day
Bodily contact Some health promoters, such as nurses, obvi-

Bodily contact is people touching each other, how ously touch patients frequently in the course of
much they touch, and which parts of the body are their work, whereas others, such as environmental
in contact. Shaking hands, holding hands, or putting health officers, would not. Touching people is
an arm around someone’s shoulders, for example, governed by rules dictated by cultural expectations
all convey a meaning from one person to another. and taboos, and by expectations of professional
distance, which may be barriers to the positive use Physical appearance

of touch. For example, a handshake can say ‘I’m
glad to see you – welcome’ and touching a dis- All kinds of messages may be conveyed by physical
tressed person can say ‘I’m here for you’. appearance, such as a person’s social standing, per-
sonality, tidy habits or concern with fashion. Physi-
cal appearance can be very important to health
Proximity promoters because of the messages it conveys. A
uniform may convey an impression of professional
Proximity is how close people are to each other. competence, but may also convey an unwelcome
Different messages are conveyed to a patient con- image of authority. Casual dress in a formal com-
fined to bed by someone who talks to him from 6 mittee may convey the impression (perhaps a false
feet away at the foot of the bed and by someone one) that the committee’s work is not being taken
who comes closer and sits on the bed or a chair. seriously.
However, people vary in the amount of personal
space they need, and may feel uncomfortable when
others come too close. Facial expression
Facial expression can obviously indicate feelings,
Orientation such as sadness, happiness, anger, surprise or
puzzlement.
How individuals position themselves in relation to
other people and objects is known as orientation. A
useful example is to consider the messages con- Hand movements and head movements
veyed by the arrangement of a room where a small
Movements of the hands and head can be very
group of people are meeting. Chairs in rows facing
revealing. Nods and shakes of the head obviously
one separate chair (perhaps with a table in front of
convey agreement and disagreement without the
it) imply that one person will dominate and control
need for words. It is important to note that move-
the meeting, whereas chairs placed in a circle
ments of the head and hands do not convey the
without a table to act as a barrier imply that every-
same meaning in all cultures. Clenched fists, fidget-
one is encouraged to join in, and that no one indi-
ing hands (and sometimes tapping feet) reveal
vidual is expected to dominate.
stress and tension, whereas still, open hands usually
denote a relaxed frame of mind. Mental discomfort,
Level such as confusion or worry, is often shown by
putting the hands to the head and playing with the
This refers to differences in height between people. hair, stroking a beard or rubbing the forehead.
Generally, communication is more comfortable if
people are on the same level; so it feels better to
bend down or sit down to talk to a child or a person Direction of gaze and eye contact
in a wheelchair, for example. Talking to someone Direct eye contact is significant. As a general rule,
on a different level can leave one or both parties a speaker looks away from the listener for most of
feeling disadvantaged. Sometimes this is done the time when talking (because they are concentrat-
deliberately; for instance, not offering a chair to ing on what they are saying), and looks directly at
someone entering an office conveys a message that the listener when they wants a response. The
the visitor is not welcome to stay. general rule is that the listener will look the speaker
straight in the eye while they are paying attention
to what they say, but will look elsewhere if their
Posture attention has wandered. This is particularly impor-
Posture is how people stand, sit or lie. For example, tant if you work with people on a one-to-one basis:
are they upright or slouched, arms crossed or not? a person who is talking to you will infer that you
Posture can convey a message of tension and are not listening if you are looking anywhere other
anxiety, for example, by being hunched up with than at them. It is critical when counselling someone
arms crossed, or one of welcome by being upright in distress; the counsellor needs to be giving the
with arms outstretched. client full attention, and if the client looks up and
sees the counsellor gazing elsewhere the implica- Raised awareness of nonverbal communication
tion is that they are not listening (see Bor et al 2008 can help you to improve communication between
for more details on the counselling process). you and the people you work with. For example, a
person who says ‘Yes, I understand’ in a doubtful
tone of voice, with a puzzled frown, clearly requires
Nonverbal aspects of speech
further explanation. Words alone are only part of a
Consider how many ways a word like ‘no’ can be message, and can be misleading. See Andersen
said. The way in which it is said can convey mean- 2007, Knapp & Hall 2007 and Mehrabian 2007 for
ings such as anger, doubt or surprise. Tone and more information on nonverbal communication
timing are two nonverbal aspects of speech which and undertake Exercise 10.6 to explore nonverbal
convey messages to the listener. communication in your work.
EXERCISE 10.6 Nonverbal communication in your work

Work through the following questions and exercises Do you think that your first impressions were
with a partner. right?
1. When do you touch people at work, if at all? What were the important features of their
What rules govern when it is acceptable/ appearance which led to your first
unacceptable to touch them? impressions?
Would people you work with be helped if you What is the importance of physical appearance
touched them more? in your health promotion work?
2. Carry on a conversation with your partner, first If you wear a uniform, or a white coat, how do you
standing too close for comfort, then standing too far think it affects your relationships with the
away. individuals and groups you work with?
What does it feel like? What is the most 7. Look around at other people in the room.
comfortable distance? What can you infer from their facial expressions,
What implications does this have for your work? hand and head movements?
3. When you talk to an individual in the course of What is the importance of noticing facial
your work, where do you sit or stand in relation to that expression, hand and head movement in your job?
person? For example, is furniture a barrier between 8. Hold a conversation with your partner while first
you? staring into each other’s eyes all the time, and then
If you talk to people in groups, how do you seat them? without looking at each other at all.
Do you think communication could be improved by Describe your feelings.
making changes? If so, what changes? Watch two people talking.
4. Have a conversation with your partner with one of Do they look directly at each other or do they
you sitting and the other standing. Both describe your frequently look away?
feelings. Do they look more at each other when speaking
Do you ever communicate with people who are on or listening?
a physically different level from you? How important is eye contact in your job?
What are the implications for your health 9. Say ‘I don’t know’ in as many ways as possible,
promotion effectiveness? trying to convey a different feeling each time, such as
5. Practise tense and relaxed postures, then welcoming despair, confusion and irritation.
and rejecting postures. How important is it for you to pick up on nonverbal
Which do you normally adopt with people? aspects of speech in your health promotion work?
6. Identify a few people you have studied or worked
with whom you know fairly well. Think back to your
first impressions of these people.
(Adapted from teaching materials produced by Habeshaw (undated).)
BOX 10.2 Guidelines on writing

1. The point of writing is clear communication. On 8. Use active rather than passive verbs where
the whole, the more simply and briefly you possible, as this is stronger and simpler. For
write, the more effective your writing is likely example, write ‘the health promoter advised the
to be. client on healthy eating’ rather than ‘the client
2. Think about what kind of document you are was advised on healthy eating by the health
writing. For example, is it a paper for a formal promoter’.
committee, a memo to your manager or a letter to 9. Make sparing use of adjectives and adverbs in
a client? This will help you to know what style to order to make your writing more striking. For
write in: formal in a set lay out for a committee, example, ‘the client was really very upset, cried
brief and to the point for a manager, business-like and sobbed a lot and said they would never, ever
but friendly to a client. come back to the smoking cessation programme
3. Think about who is reading what you write, and again’ (25 words) could be better expressed as ‘the
what sort of communication they will welcome: client was distressed and said they would never
how long should it be, how detailed, how formal return to the smoking cessation programme’
or chatty, first person or third person? (15 words).
4. Use clear, simple language, and avoid long or 10. Use language accurately. If in doubt check with a
obscure words if you can find shorter or more guide to English usage (see, for example, Peters
familiar ones. 2004, Seely 2005 and 2007, Cutts 2007).
5. Avoid technical terms if you can. If you must use 11. If you have difficulty with spelling and
them, explain them in the text or a footnote the punctuation, use a spell and grammar checker on
first time you use them. a word processor or ask someone to check your
6. Keep sentences short. writing for you.
7. Break the text up with paragraphs. A paragraph 12. If you have the time, finish a piece of writing and
should usually deal with one point and its then put it aside for a few days. This gives your
immediate development. A new point needs a new subconscious mind a chance to think about it, and
paragraph. In formal papers and reports use you can take a fresh look and edit it. Check for
numbering, headings and subheadings to break up clarity, simplicity and coherent structure.
the text and guide the reader through.
■ Good communication is fundamental to health

Written Communication promotion and involves specific skills such as active
listening.
Writing is a craft, as well as an art, which all health
■ Words, whether verbal or written, are only a small
promoters need to develop. The 12-point guidelines
part of communication, and it is important to
in Box 10.2 may help.
consider all aspects of communication.
See also Chapter 8, section on writing reports. ■ You are responsible for communicating effectively
with your clients, and it helps if you make it clear
PRACTICE POINTS to them that you accept this responsibility
(through asking them to help you by giving you
■ The quality of your relationships with your clients is feedback).
at the heart of your health promotion role. It is ■ Skills of written communication are important in
important to review and consider how your health promotion, and need to be reviewed and
attitudes and values are reflected in your developed.
professional stance.
References
Allen M, Preiss RW, Gayle BM 2002 Freshwater D 2003 Counselling Mehrabian A 2007 Nonverbal
Interpersonal communication skills for nurses, midwives communication. Edison NJ,
research: advances through and health visitors. Berkshire, Transaction.
meta-analysis. Mahwah, USA, McGraw-Hill International: Peters P 2004 The Cambridge guide to
Lawrence Erlbaum Associates. 22. English usage. Cambridge,
Andersen P 2007 Nonverbal Gottman J, Declaire J 1997 The Cambridge University Press.
communication: forms and heart of parenting: how to raise Robinson M 2002 Communication and
functions, 2nd edn. Illinois, an emotionally intelligent child. health in a multi-ethnic society.
Waveland Press. London, Bloomsbury. Bristol, Polity Press.
Bor R, Miller R, Gill S, Evans A 2008 Hartley S 2004 Bridging the gap Rollnick S, Mason P, Butler C 1999
Counselling in health care settings. between health care professionals Health behaviour change: a guide
Basingstoke, Palgrave. and communities. Community Eye for practitioners. London, Churchill
Corcoran N (ed.) 2007 Communicating Health 17(51): 38–39. Livingstone.
health: strategies for health King A 2005 PSHE: should it be Seely J 2005 Oxford guide to effective
promotion. London, Sage. mandatory? http://www. writing and speaking. Oxford,
Cutts M 2007 Oxford guide to plain teachingexpertise.com/articles/ Oxford University Press.
English. Oxford, Oxford University pshe-mandatory-210. Seely J 2007 Oxford A–Z of grammar
Press. Knapp ML, Hall JA 2007 Nonverbal and punctuation. Oxford, Oxford
Emler N 2001 Self-esteem: the cost and communication in human University Press.
causes of low self esteem. London, interaction, 5th edn. Wadsworth,
Joseph Rowntree Foundation. Thomas Learning.
147
Chapter 11
Using communication tools in health
promotion practice
Summary
Chapter Contents
The first part of this chapter offers some principles
Guidelines for selecting and producing health governing the choice of communication tools and a
promotion resources 147 summary of the uses, advantages and limitations of the
main types of health promotion resources. There are
The range of health promotion resources: uses,
guidelines for making the most of display materials,
advantages and limitations 149
for producing written materials (including guidance on
Producing health promotion resources 150 nonsexist writing) and for presenting statistical
information. This is followed by a section on mass
Presenting statistical information 151
media, including identifying the key characteristics of
Using mass media in health promotion 153 mass media, the variety of ways in which mass media
are channels for health promotion, what mass media
Using the Internet for health promotion 159
can be expected to achieve and how they can be used
effectively. Guidelines are given for working with radio,
television and local press. There is a case study on the
use of mass media advertising, and exercises on writing
plain English, preparing and presenting material on
television and radio, writing a press release and writing
a letter to the editor. The chapter ends with a section
on using information technology for health promotion.
The range of communication tools outlined in Table

11.1 are used extensively by health promoters but
may not always be employed with maximum effec-
tiveness. How communication tools are selected
and used is as crucial as the quality of the resources
themselves.
Guidelines for Selecting and

Producing Health Promotion
Resources
There is a huge range of material available, with a

constant turnover as items become out of date or
Table 11.1 Health promotion resources
TYPE OF RESOURCE USES AND ADVANTAGES LIMITATIONS
Leaflets and handouts Clients can use at their own pace and discuss with Commercially produced leaflets can be
other people. Educator and client can work through expensive and may contain advertising.
together. Can be easy and cheap to produce basic Mass-produced leaflets are not tailored
written information. Can reinforce points in a talk to everyone’s needs. Not durable, easily
and add further detailed information lost. Mass distribution can be wasteful
Posters and display charts Can raise awareness of issues. Can convey information High quality is expensive to make or buy.
and direct people to other sources (addresses, tel. Get tatty quickly unless laminated. Need
numbers, ‘pick up a leaflet’). Simple posters and to ensure any writing is big enough to
information displays can be cheap to produce be read at the distance most people will
see it Displays need changing frequently
to attract attention
Whiteboards Good for building up information, explaining particular Educator needs to turn back to audience
points. Cheap, reusable to write on board. Image too small for
large groups
Flip-charts Good for brainstorming and involving groups in Educator needs to turn back to audience
producing ideas which can be stuck up round the to write on board. Flip-chart paper
room for discussion. Useful for recording notes to be easily torn and dog eared
written up later. Can be prepared in advance. Useful
where no whiteboard available
DVDs Can be used to convey real situations otherwise Normal TV-size screen too small for large
inaccessible (e.g. childbirth), convey information, audiences. Educator relies on equipment
pose problems, demonstrate skills, trigger discussion working properly. Equipment expensive
on attitudes and behaviour. Can be used for and not easily transported. May need
self-teaching. Can be stopped, started or replayed to partially darkened room
allow discussion
PowerPoint presentation Useful in large rooms or lecture theatres with a big Needs equipment and screen, and blackout
screen. Complex information (such as graphs) can be
seen clearly
CDs Good for certain skills development, e.g. relaxation, Lack of visual material requires extra
exercise routines. Equipment cheap, easy to use and concentration to hold attention
transport
Health websites Websites have the potential of reaching a worldwide There is an enormous amount of health
audience and are useful for raising awareness of information that can be accessed on the
health issues, conveying information and delivering Internet and no control over the quality
self-help materials
out of print and new ones come on the market. You with a group of young smokers who are not moti-
could find yourself with the task of selecting a vated to stop, a leaflet or video on how to stop
leaflet, poster, display or DVD from a range of pos- smoking is unlikely to be helpful. Materials to
sibilities. Or you may find that there is very little trigger discussion with the aim of challenging atti-
available, and you have to decide whether the one tudes might be better.
item you have found is suitable.
See Chapter 14, section on stages of change model.
The guidelines are designed to help you select
any kind of material, such as leaflets or audiovisual,
and you can also use them as a checklist when pro-
Is it the most appropriate kind of resource?
ducing your own.
Will something else be cheaper and just as effective,
such as photographs instead of a DVD? Could you
Is it appropriate for achieving your aims? use the real thing, such as parents in person talking
Think about the item in the context in which you about their experiences of a new baby instead of a
intend to use it. For example, if you are working DVD; actual food instead of pictures or models?
Chapter 11 Using communication tools in health promotion practice 149
Is it consistent with your values Will it be understood?

and approach? Is it written in plain English, which people will
If your approach is to work in a nonjudgemental readily understand? Are there any incorrect
partnership with your clients, the materials you use assumptions about the level of literacy or existing
should reflect your values. You need to avoid mat knowledge? Does it need to be produced in other
erial that is patronising, authoritarian, scaremong languages, to make it accessible to people from
ering or victim-blaming. Resources should not minority ethnic groups? Do leaflets need to be pro-
attribute or imply blame to individuals experienc- duced in other formats so that they are accessible
ing ill health when that ill health is rooted in their to people with disabilities, such as in large type or
socioeconomic circumstances, for example low Braille, or for DVDs, for example, with sign lan-
income or poor housing. guage or subtitles inserted on the screen?
See section on exploring relationships with clients in Is the information reliable?
Chapter 10.
Is information in the materials accurate, up to date,
unbiased and complete? Or does it contain one-
Is it relevant for your clients? sided information on controversial issues, and out-
Does it take account of the values, culture, health of-date or incomplete messages?
concerns, age, ethnic group, sex and socioeconomic
circumstances of your clients? Does it reflect local Does it contain advertising?
practice and health services available? Commercial companies such as drug companies,
Obvious examples of irrelevance are DVDs por- baby food manufacturers or makers of safety equip-
traying lifestyles of affluent middle-class families, ment who produce material will produce leaflets
which are unhelpful if you are working with people and posters that will carry the name of the company
in the UK who have limited financial resources. or its products, or include advertisements. Using
Materials designed for one ethnic group may not be these resources can imply that you (or your
appropriate for another, not just because of lan- employer) are endorsing the product. It may also
guage but because some aspects (such as sexual damage your image as a credible source of
behaviour or attitudes to bereavement) are seen dif- unbiased health information, and lead people to
ferently in different cultures. doubt the value of the information.
For these reasons, resources containing company
Is it racist or sexist? names, products and advertising should be avoided
whenever possible. However, the item may be just
All resources should be nonracist and nonsexist. what you want, and there may be no alternative. In
Racist materials stereotype people, attributing which case:
certain roles or character attributes based on ethnic
● The product or service advertised must be
group alone. Implicit in this are the assumptions
ethically acceptable as healthy and
that one ethnic group is superior to another and
environmentally friendly. This excludes
represents the desired norm. (See Robinson 2002
tobacco, alcohol and confectionery advertising,
for information on communicating with ethnic
for example.
groups.)
● The advertising content must be low key. The
Sexist materials stereotype gender roles, behav-
company name on the front or back cover is
iours or character attributes. Resources should also
acceptable, but constant references to named-
not make assumptions about sexual orientation.
brand products are not.
Guidance on nonsexist writing is provided later in
this chapter.
Resources should reflect the fact that we live The Range of Health Promotion
in a multiracial society where the roles of men Resources: Uses, Advantages
and women have changed and continue to do so. and Limitations
Strong, positive messages and images should be
provided of people of all ethnic groups and both Table 11.1 summarises the wide range of resources
sexes. available for health promotion and the key points
about their uses, advantages and limitations. It is a few people to ensure that you have no unexpected
also important to note: ambiguities in your message.
● Resources are aids, and should generally not be Be bold. Words and pictures should be as large as
seen as substitutes for the health promoter. possible.
Leaflets should be used in conjunction with Make the most of colour. Colour can create continu-
face-to-face discussion. DVDs are best ity; for example, a repetition of background colour
presented with an introduction and a follow-up can link a series of posters. Colour can be used to
discussion. identify parts of a diagram or highlight important
● It takes time and practice to become familiar
information. Choose colours with care, because
with using all the health promotion resources responses to colour are emotional (for example,
available. green is soothing), and because colours may be
associated with certain messages, images and places
See the section on health promotion teaching and (such as red for danger, purple for funerals, white
learning in Chapter 12. for clinical cleanliness).
Improve the display site. If all you have is a blank
wall or a wall covered with distracting wallpaper,
fix a rectangle of coloured card to the wall as a
Producing Health Promotion background display board. If a display board has a
Resources rough or marked surface, give it a coat of paint or
a covering of coloured paper, hessian or felt.
Most resources, particularly posters, leaflets and Use the display site to best advantage. Busy corridors
audiovisual materials, come ready made, but you can only be useful sites for posters with immediate
might want to work with a community group to appeal and few words. More information can be
help them to produce materials that target their conveyed in a waiting area, and it may be possible
particular need, or produce some yourself. to supplement displays with leaflets to take away.
See also Chapter 10, section on written communication, Ensure that writing on displays is at eye level and
and Chapter 12, section on improving patient large enough to read without people having to
communication. move from the queue or their chair.
Be aware of lighting. Daylight is unreliable; spot-
This chapter does not offer a comprehensive lights directed onto a display are ideal.
guide on how to produce materials, but approach-
ing the task in a systematic way using the planning
and evaluation flowchart in Chapter 5 may be Making the most of written materials:
helpful. If you are producing a resource such as a instruction sheets and cards, leaflets
health promotion leaflet, you will need to consider and booklets
who will write the draft, who will edit it, whether Pilot materials on a sample of consumers. Do not
and how to pilot the draft, what it will cost and assume that you know what they like, want or
whether you need the services of a desktop pub- need: ask them.
lisher, designer, illustrator, translator or printer. Use colour, layout and print size to improve
clarity. Larger print may be helpful for those people
with a visual impairment.
Making the most of display materials:
Use plain English. Use everyday words; avoid
posters, charts, display boards and stands
jargon and explain any technical or medical words.
Be brief and to the point. Keep the objective firmly Aim for short sentences of 15–20 words. Use active
in mind. Do not include material that is irrelevant; rather than passive verbs,: for example, say ‘Increase
it will only distract from the main message. your fruit and vegetable consumption …’ rather
Emphasis the key point(s). Use size of lettering, style than ‘Your fruit and vegetable consumption should
or colour to achieve this. Place the important mes- be increased …’. Undertake Exercise 11.1 to practise
sages just above the centre of a display, which is the plain English.
point of maximum visual impact. Do a readability test on your written materials. Many
Use language the audience understands. Explain any word-processing packages are able to give readabil-
unfamiliar technical terms. If possible, express the ity statistics as well as the average sentence length
message in both pictures and words. Test it out on and the percentage of passive sentences used. They
say ‘he’ or ‘she’, it can sometimes usefully emphasis

EXERCISE 11.1 Writing plain English
that both sexes are involved. An alternative which
Write plain English versions of the following. The first has been used in this book is to turn the singular
three are very similar to the instructions found on the into a plural and use the words ‘they’ or ‘their’:
packages of medication bought over the counter in changing ‘A health promoter must be a fluent com-
chemist shops. The last three are very similar to municator. He must also be a good listener.’ To
passages in health promotion leaflets. ‘Health promoters must be fluent communicators.
1. Wheezoff paediatric syrup is specially formulated They must also be good listeners.’
for children. It is indicated for the relief of cough It may be possible to rephrase a passage to elimi-
and its congestive symptoms and for the nate the pronouns altogether. So, instead of ‘Infor-
treatment of hay fever and other allergic mation given to a social work agency is confidential
conditions affecting the upper respiratory tract. in the same way as communications between a
Contraindications, warnings, etc. Hypersensitivity doctor and his patients’, say ‘… in the same way as
to any of the active constituents. If symptoms communications between doctors and patients’.
persist consult your doctor. Another way is to use ‘you’ instead of ‘he’, ‘she’
2. Notwinge cream – directions for use. Apply a or a noun that implies male or female. For example,
sufficient quantity of balm to the part affected. in a leaflet on parenting, you could change ‘A
Massage lightly until penetration is complete. mother often finds difficulty in persuading her
3. The baby lies curled up in what is called the fetal 2-year-old to eat’ to ‘You may find difficulty in per-
position. It lies in a bag of water and the suading your 2-year-old to eat’ or ‘Parents may find
membranes which make up this fluid-filled balloon difficulty …’ This avoids the implication that only
are enclosed in the womb. mothers (not fathers) have a parenting role.
4. Vitamin B1, also called thiamin, is required for the Or avoid ‘he’ by finding another noun. Thus, in
functioning of the nervous system, digestion and ‘You may find it difficult to persuade your 2-year-
metabolism. Insufficient vitamin B1 can cause old to eat. He may prefer throwing his food around
anorexia and fatigue. instead’ you could say ‘… A child at this age may
prefer throwing food around instead.’
It is also important to avoid sexism when speak-
ing as well as writing. So, for instance, a health
promoter who refers to the women who attend a
give a rough measure of readability for adult smoking cessation programme as ‘the ladies’ could
readers based on the principle that the combination affront the women in the group. It is far better to
of long sentences and long words is harder to com- refer to the women who attend as ‘patients’ or
prehend. But note that many other factors that ‘clients’.
affect readability are not taken into account, such as
For further discussion of language barriers, see the
how the text is laid out, the use of illustrations and
section on overcoming language barriers in Chapter 10.
the size of print.
Nonsexist Writing
Presenting Statistical
The importance of material being nonracist and Information
nonsexist has already been discussed, but using
language in a nonsexist way presents particular Numbers may be meaningless to lay people unless
challenges. One is the use of ‘man’ as a generic term they are carefully presented in a visual way, such
for a person. For example, people talk about as in Figs 11.1 and 11.2. A wide range of computer
manning an exhibition stand when it is just as likely software programmes facilitates the production of
to be staffed by a woman. Many job titles end with information in ways that are visually arresting and
‘man’ and date from the time when only men per- easy to understand. NHS organisations and local
formed these duties, for example postman. authorities are likely to have the equipment and
Another problem is the generic use of the male expertise to support this production and there are
pronoun. For example, ‘Each doctor presented a Internet sites which also contain statistics repro-
case from his own practice’, assumes that all the duced visually. See, for example, the NHS Informa-
doctors are men. Although it may seem clumsy to tion Centre (http://www.ic.nhs.uk).
70
60
50
40
%
30
20
10
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Obese (BMI ≥30) Overweight (BMI >25 but <30)
Fig. 11.1 Proportion of the adult population overweight and obese. (Source: General Household Survey, Office of National Statistics
(reproduced in Black 2008: 40)).
60
50
40
% 30
20
10
0
1974 1978 1982 1986 1990 1994 1998 2002 2006
Men Women Total
Fig. 11.2 Proportion of the adult population who smoke. (Source: Health Survey for England (reproduced in Black 2008: 38)).
Using Mass Media in Health problem here is that the media may distort the
Promotion evidence with attention-grabbing headlines
which can give out unhealthy messages, such
The mass media are channels of communication to as the example in Box 11.1.
large numbers of people and include television, ● Discussion of health issues as a byproduct of
radio, the Internet, magazines and newspapers, news items (‘Rock star dies from drugs
books, displays and exhibitions. Leaflets and posters overdose’) or entertainment programmes,
are also mass media when they are used on a stand- notably soap operas/serial dramas where a
alone basis, as opposed to use as a learning aid in character has a health problem, such as being
face-to-face communication with an individual or a abused as a child or suffering from cancer.
group. However, usually when people talk about ● Health (or anti-health) messages conveyed
the media they are referring to television, radio, covertly or incidentally, such as well-known
newspapers and magazines. personalities or fictional characters refusing
Health promoters are most likely to become cigarettes or, conversely, smoking. The
involved with mass media when undertaking portrayal of alcohol on television, for example,
health promotion programmes or campaigns with conveys a norm of heavy drinking and
the public, or when a public health issue becomes associates consumption of alcohol with benefits
a news item. Probably most involvement will be rather than costs (Matthews 2007).
with local newspapers and local radio or television. ● Planned promotion of anti-health messages such
However, it is useful to put this into a wider context, as advertisements for alcohol (see Anderson 2009).
and to appreciate the range of ways in which health ● Sponsorship of health promoting events and
issues and messages are portrayed via mass media. services by organisations or commercial
companies, such as sponsorship of sporting
events by alcohol companies (see, for example
Mass Media as Tools for Health
Swanton 2009) or health promotion events by
Promotion
commercial companies (see DoH 2000 for
Health messages and information are sent through guidance on commercial sponsorship). By
the mass media in a number of different ways: associating with a health promoting event or
● Planned, deliberate health promotion, from service, the sponsor’s product or service is
posters and leaflets, displays and exhibitions on brought to the public eye with an implied
health themes, such as all of the mass media stamp of approval and a sense that it is
resources available for Change4life campaign, a somehow associated with health.
society-wide movement that aims to prevent
people from becoming overweight by
encouraging them to eat a healthy diet and take Using Mass Media for Effective
more exercise (Department of Health (DoH) Health Promotion
2009a), to advertisements and campaigns on The fact that the message is sent via a medium, such
television, such as the Worried campaign based as television, makes it difficult to obtain immediate
on teenagers’ worries about their parents feedback and modify the message to respond to the
smoking (DoH 2009b) and in newspapers (see, needs and characteristics of the audience. There can
for example, Martinson & Hindman 2005). be some two-way communication through audi-
● Health promotion by advertisers and ence phone-ins, but mostly it is one way, which has
manufacturers of healthy products and services: implications. For example, it is not possible for the
for example the Safety In The Sun leaflet produced sender to repeat, clarify or amplify the message, so
by Boots the Chemist helped convey the in general it is best to use mass media for conveying
SunSmart message by providing information for simple, rather than complex, messages.
customers (Cancer Research UK 2005). Many research studies have shown that the
● Books, television, newspapers and magazine direct persuasive power of mass media is very
articles about health issues which follow new limited and will not result in long-term changes in
research disseminated in academic conferences health behaviour (Tones & Tilford 2001). Many
or journals or government publications. The health campaigns in the media are driven by the
BOX 11.1 New health research reported in the media can mislead with attention-grabbing headlines
Low or moderate dietary energy restriction for months was not significantly different between groups
long-term weight loss: what works best? prescribed 10 or 30% ER, supporting the efficacy of low
Theoretical calculations suggest that small daily ER recommendations. However, long-term weight
reductions in energy intake can cumulatively lead to change was more variable on 10% ER and weight change
substantial weight loss, but experimental data to support in this group was predicted by body size and eating
these calculations are lacking. A 1-year randomized behaviour. These preliminary results indicate beneficial
controlled pilot study was conducted of low (10%) or effects of low-level ER for some but not all individuals in
moderate (30%) energy restriction (ER) with diets a weight control program, and suggest testable
differing in glycemic load in 38 overweight adults. Food approaches for optimising dieting success based on
was provided for 6 months and self-selected for 6 individualizing prescribed level of ER.
additional months. Measurements included body weight,
(Adjusted from the abstract of an article by Das et al
resting metabolic rate, adherence to the ER prescription.
(2009). Please refer to the article for full details.)
The 10% ER group consumed significantly less energy
than prescribed over 12 months, while the 30% ER group When the research described above was published the
consumed significantly more. Changes in body weight, Sunday Times ran an article with the following misleading
satiety and other variables were not significantly title:
different between groups. However, during self-selected
Can crash diets be good for you? New research shows
eating (6–12 months) variability in % weight change
that crash diets can be a safe and effective way of
was significantly greater in the 10% ER group and poorer
keeping the pounds off.
weight outcome on 10% ER was predicted by higher
baseline BMI and greater disinhibition. Weight loss at 12 (Goodman 2009.)
need to do something, and to be seen to be doing 3. The use of mass media is part of an overall
it. So it is important for you to know what success strategy that includes face-to-face discussion,
you can realistically expect when you use mass personal help and attention to social and
media in your health promotion work. The research environmental factors that help or hinder
evidence tells us how mass media can be used effec- change. For example, mass media campaigns
tively, and what it cannot be expected to achieve, are just one strand in a long-term programme
as follows. to combat smoking (DoH 2008).
Mass media can be an effective health promotion What mass media cannot be expected to do is:
tool if it fulfils the following criteria: 1. Convey complex information.
1. The information portrayed is: 2. Teach skills.
– perceived as relevant 3. Shift people’s attitudes or beliefs.
– supported by other approaches such as 4. Change behaviour unless it is a simple action,
one-to-one advice easy to do, and people are already motivated to
– new and presented in an appropriate context. change.
2. The aim should be to: See Naidoo & Wills (2009) for a more detailed
– raise awareness of health and health issues analysis of the mass media and health promotion
(for example, in order to trigger action to and Wammes et al (2007) for research into the
raise awareness about the impact of smoking effectiveness of a mass media campaign aimed at
on family members) weight gain prevention.
– deliver a simple message (for example, to
make quitting easier by providing details of
a national helpline for people who want to Creating Opportunities
stop smoking) You may be motivated to use the mass media, but
– change behaviour (for example, to reinforce you may have misgivings and feel the need for
motivation and make quitting easier by further training. For example, you may feel appre-
phoning for a leaflet or other support). hensive of interviews with reporters from the local
news media because of concerns about being mis- The programmes

quoted or that the media might sensationalise the
● What is covered on the news items?
issue or that you will not perform effectively.
What can be done to overcome these concerns? ● How many minutes of current affairs and local
Some NHS organisations and local authorities interest items?
now have guidelines for dealing with the media ● Are interviews used, or straight reporting?
(for example, Fay 2002, Jones & Hutchings 2003) ● What are the different kinds of programmes,
and some professional bodies offer advice to and what is the proportion of time they occupy
their members in terms of media involvement (news, current affairs, weekly events, phone-
(British Medical Association 2004) and some ins, music)?
employ communications specialists, and their help ● Which programmes use guests or experts?
can be enlisted (see Thake & Glendinning 2009 ● Is there any local programme that regularly
for an example of a media release from NHS covers health issues?
Cambridgeshire). ● Is there a round-up of events in the week
Contact local journalists to establish a mutually ahead? What is the deadline for information?
beneficial relationship. You can give exposure to
● How much detail do they give? What sorts of
health topics and they want items for their reading,
events are covered?
listening or viewing public. Get to know how they
work and their special areas of interest. Also,
remember that it is in both your interests to have Interviews
good skills in communicating via the mass media,
● Which programmes use interviews?
so ask for help with training needs. Short courses
on using the media may also be available. ● How many minutes?
Keep a record of what you find out about local ● What is the tone (bland, chatty, aggressive)?
media, and update it regularly. Include information ● How long is the average answer before the next
on names and special interests of journalists and the question? Time it!
copy dates (deadline for submitting written infor- ● Are they on location or in the studio?
mation) for each of the media in your area. The ● Are they recorded or live?
daily newspapers should be able to respond imme- ● Who are the presenters or interviewers on the
diately to a press release; radio often needs a few programmes who might be interested in
days to prepare coverage; television may need health? What is their style?
longer advance notice to allow time for booking a
film crew.
Finding out about a specific programme
● What programme is it? What sort of approach
Working with Radio and Television does the programme have? How long is it?
Using radio or television effectively requires When is it transmitted? What kind of audience
research, preparation and skill. The following does it have?
checklists are prepared to help you get your health ● Why is your topic of interest now? Is there
promotion story to the right person and have the some local or national controversy or news
best chance of getting coverage. You need to item that sparked off interest? If so, do you
monitor your local radio and television to see which know all about it?
programmes might be interested in your kind of ● How are you going to be presented: an infor
news. mation spot, an interview or a discussion
panel?
● If you are going to be interviewed, who will do
Basic information it? Will it be in the studio, on location or a
● What hours do they broadcast? telephone interview?
● What region do they cover? ● If you are going to take part in a discussion,
● Who are the listeners? Does the profile alter who else will be taking part?
according to the time of day? ● Will it be broadcast live or recorded first?
● How much time are you likely to have on the ● Make sure you say what you want to say. You
programme? do not have to follow the line of the
● When and where is the broadcast or recording interviewer’s questions if, for good reason, you
to take place? do not wish to. Provided you stick to the broad
framework of agreed subjects, you have every
right to steer the interview or discussion in
Preparing the message such a way that you get over what you want to
● Do your homework. You may know a lot or a say. Regard the questions as springboards from
little about the subject, but in either case you which to make your points. For example, if you
need to identify exactly what it is you want to do not like a question you can say:
get across, and to have this very clearly in your ‘I can’t really answer that question without
mind before you go on air. explaining first that …’
● Be positive. Emphasis the good news, not a ‘The real problem behind all this is …’
series of don’ts. Tell people what they can do ‘We don’t know the answer to that at the
and emphasis the benefits. moment, but what we do know is …’
● You should have two or three key points to put ● When the interview is over, remain still, quiet
across, and no more. You can expand on these and alert until you are told it is over.
and describe them in different ways but do not ● On television, wear what makes you feel
overload your audience with too much detail comfortable and confident. Avoid wearing blue
or too many points. They will not remember or bright red, predominant stripes, small
the additional information, and may even patterns or flashing jewelry. As the camera will
forget the key points. be on your face for most of the time, pay
● Use anecdotes and analogies to illustrate what special attention to what you wear in the
you mean; simple messages do not have to be neckline area.
bald and boring. Tell stories (short ones) and Practise your media skills by undertaking
use real-life experiences. Put complex points Exercise 11.2.
over with everyday analogies.
● Avoid technical terms (unless these are Working with the Local Press
essential, in which case use them and explain
them) and jargon, but do not be patronising. It Local community newspapers are an excellent
helps to pitch the level right if you imagine that medium for health promotion and journalists will
you are talking to an intelligent 14–15-year-old be interested in newsworthy health issues. This is a
whom you have never met. checklist of what to look for when researching a
newspaper.
Presenting your message Basic information

● If you are nervous, regard it as positive; it
● Is it published daily or weekly?
means that you will be keyed up to do your
● What are the copy deadlines?
best. Remember that the interviewer is there
● What locality does it cover?
to help you tell your story and to put you at
ease. ● How many readers, and who are they?
● Perform with liveliness and conviction. Be alert
and (if you are on television) look alert at all The copy
times. Always assume that the camera is on
● What is the style (bright, sober, campaigning)?
you even when you are not talking. Make sure
● What is the average length of articles (often
you look convincing and involved.
different for news, business, features)?
● Speak with your normal voice; if you have
● What percentage of articles have photos?
a regional accent this will make you more
interesting to listen to. Speak clearly and ● How many photographs per page?
distinctly, and (especially on radio) vary the ● How are photographs used generally?
pitch and speed. ● How are quotes used?
EXERCISE 11.2 Being an effective health Your special interests

promoter on television and radio ● Anything in the papers that may be of special
1. Prepare your message use to you or to your organisation?
Select a health promotion topic that you are familiar
Gradually build up expertise, with a fact sheet on
with, such as healthy eating, sensible drinking,
each newspaper. This will be indispensable for tar-
breastfeeding, keeping fit, avoiding home accidents.
geting your press releases.
Identify three key points you would want to put
across in a 5-minute radio or television interview. Be How to write a press release
clear in your mind:
■ What the three key points are. To write a press or news release you need to con-
■ How you will explain them in an interesting way, sider the following:
what illustrations, analogies or anecdotes you Headline. Create a catchy headline that is short
could use. and simple using less than 10 words. It should
■ How you will develop your point further if you convey the key point made in the opening para-
have time. graph in a light-hearted manner that catches imagi-
nation and attention.
2. Practise your presentation Collate and organise your facts. A simple rule is
Get a colleague to act as your interviewer, and record to find answers to questions pertaining to the
your interview on an audio or a videotape. Ask a third five Ws: Who, What, When, Where, Why and then
person to be an observer. Play the tape back and assess How. Identify your story’s angle. A good story
your performance. angle must have the following attributes. It must
■ Did you sound/look lively, alert and convincing? be the most important fact in your story, it must
■ Was your voice clearly understandable? What did be timely, it must be unique, newsworthy or
it sound like for speed and pitch? contrary to trends. The story angle must be pre-
■ Did you get your key points across? Did you do so sented in the first paragraph. Make your points
in an interesting way? in order of importance. Use short sentences,
■ Were you able to deal with difficult questions? brief paragraphs and easy language, with no
abbreviations or jargon. Put the most important
message down into a quote. Journalists use quotes
from the newsmakers to add an authoritative voice
The subjects to their reports. If the press release contains quotes
● What sorts of stories are used (local, that are important and relevant they have more
controversial, educational) and how are they chance of being replicated in full in the published
treated? article.
● What is the ratio of coverage for news, features, Keep to one page if possible. If longer, type ‘More
business, diary, advertisements? follows …’ at the bottom right hand corner. Do not
● How long and how full is the section
carry over paragraphs or sentences to the next page.
publicising events ahead? Type ‘ends’ after the last line of the release. End the
press release with brief background information on
● Are there special sections or supplements on
your organisation and who to contact for further
health, education, women? How long and on
information.
what day?
Be specific. Focus on people rather than making
● Are there regular columnists? What are their
generalised statements or quoting dry statistics. For
special interests? example, say: ‘Last week three Bloggsville children
were admitted to the Royal Infirmary after acciden-
The language tally swallowing weed killer. This brings the number
of children accidentally poisoned this year to over
● What is the average length of sentences? 100. Sister Florence Nightingale, in charge of the
● What is the average length of paragraphs? Accident and Emergency Department, said: “It is
● What kind of language is used (multisyllabic, heartbreaking to see the needless distress this
slang, turgid, lively, short and simple)? causes” …’
Timing is vital. Your press release may not be used

BOX 11.2 Press release
if a) it comes out on a day when there is news over-
load, such as on the day of election of a new prime Kofftown Primary Care Trust
minister; b) the news is not topical or current. Alert PRESS RELEASE 1st September 2010
newspapers a few days in advance so that they can SMOKERS HOTLINE LAUNCHED
send reporters to cover an interesting event. For Kofftown’s Smokers Hotline got off to a flying start
example, contact on a Friday or Monday is usually this week, when Jo Goodheart, a health promotion
best for a weekly paper published on the following specialist at Kofftown PCT, launched the service.
Friday. If you want to launch a story at a particular
time, use the embargo system. This means writing, The hotline has been set up as part of Kofftown’s
for example, ‘Not for use until Wednesday Septem- Heart Week (1st–10th September), to help people
ber 2nd 2010’ or ‘Embargoed 6 p.m. September 2nd who want to stop smoking. Anyone ringing 1234 567
2010’ across the top of the press release. If it is for 890 will be sent a free pack of useful ideas to help
immediate release, then state: FOR IMMEDIATE them give up, including tips from ex-smokers and
RELEASE. information about local stop-smoking groups.
Presentation. Use A4 paper, headed with a logo if ‘I smoked myself when I was younger and I
possible. Colour catches the eye, so a coloured remember what a struggle I had to stop. Many of my
heading or coloured paper will make your release clients also find it incredibly difficult’, said Joe
stand out. Journalists work at speed, so make their Goodheart. ‘That’s why I’m delighted to launch this
task easier by: scheme. The pack has lots of useful information to
● Using only one side of the page, placing the help people over the difficulties.’
text centrally on the page.
Smokers have a two to three times greater risk of
● Using a lay out with double spacing. having a heart attack than nonsmokers. At least 80%
● Leaving at least a 1-inch (2–3-cm) margin on of heart attacks in men under 45 are thought to be
either side. due to cigarette smoking. Stopping smoking could
● Putting a release date or embargo date at the top. lead to 150 fewer deaths each year of men and
● Giving names and telephone numbers of people
women under 65 in Kofftown.
in your organisation for further information For further information, please contact:
(including an after-hours telephone number).
Jo Goodheart, Senior Health Promotion Officer, PCT,
● Sending it to a named journalist if possible.
People’s Lane, Kofftown KT1 2YZ
● Not underlining any words (because this gives
printers instructions to use italics; use bold for Telephone 1234 246 802 (day) or 1234 135 790
emphasis instead). (evenings)
Photographs. If you are sending a photo, a 7 × 5 or

10 × 8, generally black and white, is preferred, with
a full label on the back giving names and details.
Include the names of everyone on the photo the The above is based on ideas from Pressbox: press
picture shows, for example, ‘left to right June release writing (http://www.pressbox.co.uk). There
Bloggs, Director of Public Health, Sam Smith, are many websites with excellent ideas for writing
Health Promotion Specialist …’ and explain what press releases for the media. These can be found by
they are doing ‘presenting Healthy Eating awards simply using Google and the search term press
at 3 p.m. on Tuesday March 10th at Bloggsville release. See also the example of a press release in
Town Hall’. Never write directly on the back of a Box 11.2.
photo, as this will destroy its quality. Photos should
be eye-catching and clear.
Writing letters to the editor
Communication. Send a copy of the press release
to everyone who will be affected, including your Another way of using the local paper as a medium
organisation’s communication or press officer, and for health promotion is by writing letters to the
to everyone mentioned or otherwise involved in the editor. This can keep an issue in the public eye for
story. some time, and provides good opportunities for
which provide easy access to the best available

EXERCISE 11.3 Writing for the local paper
information on what works to improve health and
1. Write a press release about a public health issue reduce inequalities, including effectiveness reviews
you are currently concerned about or working on, that can be downloaded. These websites include
such as healthy school meals, binge drinking, drug the National Institute for Health and Clinical
taking by young people in local clubs, lack of play Excellence (NICE) (http://www.nice.org.uk). The
facilities for young children or poor public Cochrane Centre (http://www.cochrane.co.uk)
transport. produces and disseminates systematic reviews and
2. Write a letter to the editor supporting a current promotes the search for evidence in the form of
health promotion campaign or drawing attention clinical trials and other studies of interventions. The
to a specific need for health promotion. Cochrane Collaboration is named after the British
epidemiologist Archie Cochrane.
Those health promoters working in a health
setting can access Health Information Resources,
public debate of controversial issues. Letters to the formerly National Electronic Library for Health,
editor should be to the point, short (some news which aims to provide accredited reference mat
papers restrict length) and be on one topic only. erial for evidence-based practice. Other electronic
Practise writing a press release and a letter to the databases that can be accessed include CINAHL
editor by undertaking Exercise 11.3. and Medline.
Using the Internet for Health Disseminating Resources and Infor-

Promotion mation to Other Health Promoters
Organisations in which health promoters are
The Internet has revolutionised the way health pro- located will generally have their own websites, and
moters and the general public gain access to health use them to disseminate reports of local projects
information. Because of the massive growth of and locally produced health promotion resources.
Web-based health information, the global nature of Leaflets and resource packs are often available in
the Internet and the absence of real protection from PDF format so that visitors to the website can
harm for citizens who use the Internet for health download the materials for their own use.
purposes, quality is regarded as a problem (Risk The Department of Health website (http://
& Dzenowagis 2001). Health promoters can use www.dh.gov.uk) (and the Irish, Scottish and Welsh
He@lth Information on the Internet, a journal which equivalent) is an excellent resource for health
offers a guide to the most useful health websites promoters and contains significant amounts of
and offers invaluable tips on how to find the in policy and campaign/programme information and
formation you and your clients need. resources.
The Internet can be used to:
● support evidence-based health promotion
Providing Information and Support
practice
to the Public
● disseminate resources and information to other
health promoters A key objective of health policy (see, for example,
● provide information and support to the public. DoH 2004) is to provide fast, convenient access for
the public to accredited multimedia advice on life-
See the section on evidence-based health promotion in style and health. One result of this has been the
Chapter 7. establishment of NHS Direct online (http://www.
nhsdirect.nhs.uk) which aims to provide expert
health advice and information.
Supporting Evidence-Based
Many health websites are read-only and are used
Health Promotion
to publish information for the user, a one-way
The Internet provides the means of acquiring process. But some also allow the user to interact.
research evidence on the effectiveness of health There are sites that offer interactive health guides
promotion. There are a number of key websites such as the Department of Health site designed to
support people in safe drinking (http://www. way of checking this out? If the information is
drinking.nhs.uk) by providing a unit calculator, new, is there any proof?
drink diary, advise on how to cut down and other 6. When was the site produced and last updated?
valuable materials. The Department of Health also Is it up to date? Can you check to see if the
uses YouTube (http://www.youtube.com). information is up to date, and not just the site?
These examples of e-health can be useful tools 7. Is the information biased in any way? Has the
for health promotion. There is a growing body site got a particular reason for wanting you to
of debate about the effectiveness of computer- think in a particular way? Is it a balanced view ?
generated interventions (see Korp 2006, for 8. Does the site tell you about choices open to
example), and the volume of websites and blogs you? Does the site give you advice? Does it tell
will present serious issues about the quality and you about other ideas?
accuracy of health advice.
PRACTICE POINTS
■ Communication tools for health promoters are wide
Assessing the Quality of ranging and need to be selected carefully and used
Information on the Internet effectively, with an assessment made of the
It is important that health promoters evaluate the advantages, uses and limitations of each kind of
quality of any website they use and/or advise their resource.
clients to use before trusting the information it ■ Consider factors such as site, colour, language and
provides (see Lewis 2006 for an interesting debate style when creating displays.
on the use of the Internet by the lay public). The ■ Written materials should be nonsexist, nonracist, in
following guidelines adjusted from LEARN NC plain English and accessible to everyone, for
(http://www.learnnc.org) may be useful in assess- example, ethnic minority languages, large type or
ing the quality of a website: alternative formats such as audiotape instead of
1. Who has written the information? Who is the written materials.
author? Is it an organisation or an individual ■ Present statistical information with appropriate use
person? Is there a way to contact them? of graphics to ensure clarity.

■ You can use mass media successfully to raise
2. Are the aims of the site clear? What are the
aims of the site? What is it for? Who is it for? awareness of health issues and deliver simple
messages. You are unlikely to be successful if you
3. Does the site achieve its aims? Does the site
try to use mass media to convey complex
do what it says it will?
information or skills, or to shift attitudes, beliefs
4. Is the site relevant to me? List five things you or lifestyle.
want to find out from the site. ■ Work effectively with local media by researching
5. Can the information be checked? Is the author potential opportunities and carefully preparing
qualified to write the site? Has anyone else said presentations and press releases.
the same things anywhere else? Is there any
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Society 28(4): 521–539. together to help the people of departmentofhealth
163
Chapter 12
Educating for health
Summary
Chapter Contents
The first section of this chapter involves a discussion
Principles of learning for health 163 on the principles of learning. An exercise is used
to analyse the qualities and abilities of an effective
Facilitating health learning 164
health educator, and some principles of facilitating
Guidelines for giving talks 170 health learning are outlined. Subsequent sections
contain guidelines on giving talks, strategies for
Improving patient education 173
patient education and teaching practical skills for
Teaching practical skills for health 174 health. A role-play exercise is used to focus on skills
of effective patient health education.
This chapter is about the skills and methods of edu-

cating for health, when the aims are primarily con-
cerned with enabling people to acquire health
knowledge and skills. Examples are: giving a talk
on a health topic to a large community group;
teaching an adult education class in food safety or
a school class in sexual health; running cardiac
rehabilitation sessions for patients recovering after
heart attacks; giving information to a patient on a
one-to-one basis about diagnosis, treatment and
self-care; or teaching a small group of colleagues
about the techniques and procedures used in a
smoking cessation programme.
Principles of Learning for Health
Some aspects of education, teaching and learning

are relevant for health promoters.
Other relevant Chapters are 10, 11, 13 and 14.
Health promoters generally have credibility

BOX 12.1 Principles of learning as applied
to health education because of their training and expert knowledge
which is likely to be valued and respected by clients,
■ Learning for health is most effective when the but expertise alone does not make a good health
learner identifies their own learning needs and educator. In order to get results in the form of meas-
sets their own goals. urable learning achievements, such as greater re
■ The health educator’s role is to enable or facilitate tention and application of health information and
learning rather than to direct it. Health educators skills, health educators need to understand some
who adopt this approach often refer to themselves principles of learning, such as the importance of
as facilitators. participative learning. The basic principles of learn-
■ Learners are generally most ready to learn things ing as applied to health are summarised in Box 12.1.
that they can apply immediately to existing health For more details on adult learning see Rogers (2001);
problems or to their own situation. for an example of how the principles of learning can
■ Learners bring with them life experience, which be applied in practice see Suter & Suter (2008); for
should be seen as a resource and to which new a broader perspective on teaching and learning in
learning should be related. nursing health promoting practice see Bastable
■ Learners can help each other, because of their (2002); and for health settings generally see Bastable
experiences, and should be encouraged to do so. (2004).
■ Learning is best when active (not passive), by
doing and experiencing, for which learners need
a safe environment where they feel accepted. Facilitating Health Learning
■ Learners should be encouraged to carry out
continuous evaluation of their own learning. Exercise 12.1 will help you to identify factors that
Health educators should use this evaluation to have helped and hindered your learning, and to
fit the learning process to the learners’ needs. assess your own qualities and abilities. The follow-
ing recommendations apply to health education
with individuals or groups.
EXERCISE 12.1 What helps and hinders learning?

Think of two occasions when you have been a learner, muddled? used words you didn’t understand? used
such as when you were a health promotion student in audiovisual aids effectively?)
class, or in the audience listening to a health talk, or Enter these factors on the chart:
when you were being taught on a one-to-one basis.
These learning occasions need not have been connected Environment Teacher Presentation
with work, for example listening to an art lecture or Factors that
taking a driving lesson. One should be when you felt, helped
overall, that the session was good and the other when it Factors that
was bad. The aim of the exercise is to identify the factors hindered
that made them good or bad for you.
In each of your two situations in turn, identify factors If you are working in a group, compare your chart with
that helped you to learn, and factors that hindered your those of other people.
learning. Think of these factors in three categories: ■ What have you learnt about the importance of the
1. Those to do with the environment (e.g. too hot? environment?
noisy? hard chairs? a spacious, comfortable ■ What qualities of a good health educator do you
room?) think you already possess?
2. Those to do with the qualities of the teacher (e.g. ■ What helpful points about presentation do you
sense of humour? appeared bored? contagious think you already use, or will use, in your own
enthusiasm? seemed unfriendly?) work?
3. Those to do with the presentation (e.g. talked too ■ What points about your own qualities or
long? used relevant illustrations? involved audience? presentation would you like to improve?
Chapter 12 Educating for health 165
Plan Your Session cover what I want to teach or what my clients want
to learn?’
However skilled and knowledgeable you are about Second, keep your clients involved as much as
the health topic, it is vital to put thought and time possible during sessions. This is a challenge if you
into preparation. You need to think through what are giving a talk or a lecture to a large audience, but
you aim to achieve, how you are going to introduce there are possibilities, such as asking people to
and develop your session and how you will involve respond to a question, such as ‘I’d like you to put
your audience. Preparation is especially important your hand up if you made a new year resolution to
when facilitating health learning is new to you, but take more exercise this year’. Or ask them to respond
even the most experienced and self-confident health to a series of statements: for example, as an intro-
educator needs to spend some time in preparation. duction to a talk on nutrition, ask the audience to
Active participation is a more complex process and stand up, then ask them to sit down if they: usually
will require greater attention to planning. eat white bread … add sugar to tea and coffee …
regularly eat fried food … add salt at the table …
Work from the Known Most of them will be sitting down by now but will
to the Unknown feel alert and involved. Another way of keeping an
Time is wasted in teaching people something they audience involved is to give them time to talk. This
already know so the starting point is finding out can be done by having question-and-answer ses-
what your clients know. If you cannot do this in sions, or by allowing short breaks when they can
advance, spend some time at the beginning of talk about something in groups of two or three for
the session asking a few questions. If you have a a few minutes. In a talk on passive smoking, for
mixed audience with varying degrees of know example, you could give your audience a couple of
ledge, it may be best to acknowledge that some minutes to tell their neighbours how they are
people know more than others, and you will have affected by other people’s smoke.
to make a decision about the level at which to pitch You can also keep people involved with eye
your information: ‘Some of you will probably know contact. Make sure that you look round at every-
this, but I’ll talk about it briefly because it will be body, not just the people immediately in front
new to others …’. of you.
Your aim is to impart new health information, or
new skills, onto what is already known. Vary Your Learning Methods
It is natural to consider health educating from the
Aim for Maximum Involvement
health educator’s point of view but it may be more
People learn best if they are actively participating helpful to look at it from the learner’s point of view.
in the learning process, not just passive listeners For example, talking for half an hour demands con-
(see Jenson & Simovska 2005 for an interesting dis- centrated effort and total involvement on your part;
cussion of two models of participation). but all your audience is doing is listening, which
First, where appropriate, involve your clients in involves only one of their senses and is highly
deciding the aim and content of the session. If you unlikely to hold their full attention.
are running a course, such as a series of antenatal Variety can be brought into health teaching in
classes or one on food hygiene, you might begin by many ways, including strategies that can be used
explaining your aims, asking for comments and with individuals, groups, large audiences, children
suggestions, and then going on to discuss the or adults; see Table 12.1 for ideas.
content. This will help to increase motivation by
stimulating clients to think about their own needs
Devise Health Education Activities
and to take some responsibility for their own learn-
ing. The goals and content of a one-to-one session Listening is passive; activities are the means by
can be established by mutual agreement at the which you help learners to think through what is
outset. As a general rule, it is worth considering being said and act on it, in their own way. It is not
how much room for negotiation there is in your sufficient to ask a group ‘What do you think?’ at the
health education role, and spending time to find out end of a talk or after viewing a DVD; planned activ-
what people really want. Ask yourself ‘Is what I ities are necessary to help people to explore and
Table 12.1 Learning methods involving clients
CLIENT INVOLVEMENT MATERIALS AND METHODS
Listen Lectures, audiotapes

Read Books, booklets, leaflets, handouts, posters, whiteboard, flip-chart, PowerPoint slides
Look Photographs, drawings, paintings, posters, charts, material from media (such as
advertisements)
Look and listen DVDs, PowerPoint, demonstrations
Listen and talk Question-and-answer sessions, discussions, informal conversations, debates, brainstorming
Read, listen and talk Case studies, discussions based on study questions or handouts
Read, listen, talk and actively participate Drama, role-play, games, simulations, quizzes, practising skills
Read and actively participate Programmed learning, computer-assisted learning
Make and use Models, charts, drawings
Use Equipment
Action research Gathering information, opinions, interviews and surveys
Projects Making health education materials – DVDs, leaflets, etc.
Visits To health service premises, fire station, sewage works, playgroups, voluntary organisations
Write Articles, letters to the press, stories, poems
For discussion of some of these methods, see Chapters 13 and 14; for discussion on the use of audiovisual aids, see Chapter 11.
Table 12.2 Common types of learning activities
TYPE OF ACTIVITY EXAMPLE
Guidelines for discussions with particular Guidelines on ‘what to do if you think your child is offered drugs’ for discussion at a
people about particular topics parent–teacher meeting
Analysing and discussing diary records Ask people to keep a diary or write down what they ate or the alcohol units they
consumed in the last 24 hours. Ask them to talk about what they are pleased
about and not pleased about
Sentence completion Ask people to complete a sentence such as ‘I feel really stressed when …’
Using checklists Have a list of ‘ways to make small changes to my lifestyle’ such as taking the stairs
and not the lift, walking (or cycling to work), joining an exercise class, and discuss
how many you use
Identifying your own thoughts/feelings/ Ask people to think about and discuss what they feel when visitors to their home ask
behaviour in particular situations if they can smoke, and how they respond
Generate lists Ask a group to make a list of all the ways they could deal with an obese client who
will not comply with advice on healthy eating
Answer sheets A quiz with yes/no or multiple answers on ‘How much do you know about sensible
drinking?’
Drawing charts or bubble diagrams Draw a stick-person picture of yourself in a supermarket in the middle of a page.
Draw bubble thoughts about all the things that influence what food you buy
Writing instructions Ask a group learning about food hygiene to write down instructions for someone else
on how to store food safely in a fridge
Practical skills development Practise bathing a baby using a doll or a real baby.
apply ideas, feelings, attitudes and behaviour. It is There are also ideas in some of the exercises used
more effective to have a mix of activities that are throughout this book.
specifically tailored for a particular group of learn-
ers, so where possible develop the skill of devising
Ensure Relevance
your own activities rather than relying on learning
aids made for general audiences. There is an almost You should ensure that, as far as possible, what you
infinite range of possibilities. Some of the more say is relevant to the needs, interests and circum-
common types of activity are set out in Table 12.2. stances of the clients. For example, recommenda-
tions about health-promoting activities that cost withdrawal. Learning contracts are an agreement,
money may not be useful to an audience which has decided together, about what is to be learnt. By
no money for extras. A discussion on childhood participating in the process of diagnosing needs,
vaccination may be irrelevant to a pregnant woman formulating goals, choosing methods and evaluat-
whose overwhelming concern is the birth itself; she ing progress, learners can develop a sense of owner-
may not relate to an issue that will not meet her ship of the plan, and feel more committed and
immediate needs. empowered.
You will help your clients to see the relevance of The stages of developing a learning contract are
your subject if you use concrete examples, practical described below.
problems and case studies to explain and illustrate
your points. It may be more difficult for your clients
Step 1: Diagnose health learning needs
to relate to abstract generalisations, quotations of
with the learners
statistics or epidemiological evidence. For example
say ‘one person in ten’ instead of ‘X million people First, decide the competencies required to carry out
in this country’, tell the story of a home accident actions, behaviour or roles. A competency can be
rather than describe a list of risk factors, and thought of as the ability to do something, and it is
describe ‘increasing the risk’ by saying ‘It’s like a combination of knowledge, understanding, skills,
driving a car with faulty brakes, there’s no guaran- attitudes and values.
tee that you will have an accident, but your chances For instance, the ability to ride a bicycle from
of having one are greater’. home to school involves knowledge of how a
bicycle works and of the route from home to the
school; understanding of the risks inherent in
Identify Realistic Goals
riding a bicycle; skills in mounting, pedalling, steer-
and Objectives
ing and stopping. It is useful to analyse competen-
In Chapter 5 there was a discussion on the impor- cies in this way, even if it is crude and subjective,
tance of clearly identifying health promotion aims because it gives the learners a clearer sense of
and objectives, but it is worth emphasising again direction.
that it is essential to be clear about what you are Next, assess the gap between where learners are
trying to do (raise awareness of a health issue? give now and where they should be in regard to each
people more health knowledge?) and what you health-related competency. Learners may wish to
want your clients to know, feel and/or do at the end draw on the observations of friends, family or
of your session. As mentioned above, your clients experts to make this assessment. Each learner will
should be involved in these decisions. then have an idea of the competencies needed and
a map of their health learning needs.
See Chapter 5, section on setting aims and objectives.
Three or four key points are all that clients

Step 2: Specify the learning objectives
can be expected to assimilate from a session. Includ-
of each learner
ing more than that does not mean that they learn
more; it usually means that they forget more. For Translate the learning needs identified in step 1 into
example, if you are asked to give a talk on a huge objectives that describe what each learner wants to
theme, such as food for health, avoiding accidents, learn. All learners should state their learning objec-
first aid or pollution, you will need to select what tives in terms most meaningful to them. For
you feel to be the few points most relevant for your example, in order to ride a bicycle from home to
audience, and avoid the temptation to include school, learners may decide that they need know
everything. ledge of how to work the bicycle gears and improved
skills of steering and stopping safely.
Use Learning Contracts
Step 3: Specify learning methods
In some educational settings the learner is told what
objectives or targets to work towards. This can con- Review the learning objectives of the learner or (if
flict with some people’s psychological need to be you are working with a group of learners) all the
self-directing and may induce resistance, apathy or members of the learning group, perhaps through
listing them on a flip-chart and identifying shared Organise Your Material

objectives and areas of difference. Now think about
how you could go about accomplishing these objec- Whether you are talking to a group or an individ-
tives. Specify the methods you would use. In the ual, it helps if you organise your material into a
bicycle example, you could specify that practical logical framework, and tell your client(s) what this
demonstration followed by supervised practice in a is, both at the beginning and during your teaching
traffic-free area would be the way to learn. Ask session. For example, with an individual client in a
learners to suggest the methods they prefer. smoking cessation course, say:
‘We are going to:
Step 4: Evaluate learning • Look at your smoking behaviour and the reasons why
you smoke.
Now describe what evidence you will need to show • Identify the barriers to you giving up smoking.
that these objectives have been achieved. For • Measure where you are in terms of your motivation
example, knowledge can be tested through quizzes; to stop smoking.
understanding can be tested through solving prob-
First, let us discuss your smoking behaviour and what
lems; skills can be tested through demonstrations
prompts this behaviour.
of performance; attitudes can be tested through
role-play and simulation exercises; values can be Second, what do you think will prevent you from
tested through line debates and value-clarification stopping …
exercises. Finally, let us see where you stand in terms of you
wanting to stop smoking …’
See also Chapter 5, section on planning evaluation
methods. The same principle applies if you are talking to a
group. You tell them what you are going to tell
An example of a learning contract for a group is
them; tell them; then tell them what you have told
provided in Box 12.2. Individuals in a group can
them! This helps both you and the audience to
have their own personal version of the learning
know where you are and where you are going.
contract.
Recapping where you are at intervals is helpful:
See Chapter 14, section on strategies for increasing ‘That’s all I’ve got to say on the benefits of yoga;
self-awareness, clarifying values and changing attitudes. now, to move on to how you can get started …’,
BOX 12.2 Learning contract for Mary’s young parents’ group

Group members said they wanted to know more about how to cook cheap, interesting, healthy meals for their families,
as a change from the usual ready prepared foods such as frozen fish fingers, cans of beans, frozen chips. Mary and group
members worked out the following learning contract.
Evaluation of achievement
Learning objectives Learning methods of objectives
Know what to eat to be healthy Keep food diaries for 2 days. Mary to Be able to say what sort of food each
produce guidelines and members member should aim to eat more or
discuss how far their food matches less of
up to guidelines
Know where to buy healthy cheap Group members share experience of Two weeks later, members identify
food where they buy food, its price and changes in where they buy food,
quality and whether it is better quality
and value for money
Be able to cook healthy meals that Mary and group members bring recipes, Have cooked new healthy meals at
their families enjoy eating choose some to try out and cook home
together
or ‘Now I’d like to move on to my third and final Getting feedback

point, which you may remember I said was
about …’ You could include oral feedback as part of your
session. For example, at the end ask people to do a
round of sentence completion:
Evaluation, Feedback ‘The thing I liked best about today’s session
and Assessment was …’
It is important to get feedback, so that you can ‘The most important thing I am taking from
assess how much your client is learning and this session is …’
improve your own performance in the future. ‘The thing I liked least about today’s session
See Chapter 5, section on planning evaluation methods, was …’
and Chapter 10, section on asking questions and getting However, people may find this intimidating, and
feedback. might not feel comfortable with expressing what
they feel. You may wish to use a written evaluation
form; see the two examples in Boxes 12.4 and 12.5.
Assessing your own performance
You need to ask yourself what went well, what Assessing the health learning outcomes
didn’t, why and how things could be improved
next time. You may find it helpful to use a simple Assessing learning outcomes is an important aspect
form to record your thoughts. This is especially of evaluation in health education. It is the process
useful if your session is part of a course with a of measuring the extent and quality of your clients’
team of people involved. An example is given in learning: judging how successful they have been in
Box 12.3, a form used by a group facilitator to record progressing towards goals which they set them-
issues after a group session on healthy eating and selves. It may be carried out very informally through
cooking. getting apparently casual feedback from clients
about how they have applied the learning to real-
life situations, or it may involve setting tests in
formal situations. Here are two examples of ways
in which health promoters assess how well they are
doing:
1. Sandra teaches yoga. She does not feel it
BOX 12.3 Nutrition and cooking project appropriate to assess her students formally, so
monitoring form she uses the British Wheel of Yoga standards to
check on their performance and give them
Session no:
feedback.
Date:
Time: 2. Marleen teaches cookery and healthy eating to
Facilitator: adults with learning difficulties. She keeps
Number of attendees: records of their progress in relation to their
Number in crèche:
Activity:
Positive outcomes: BOX 12.4 Evaluation form A
Negative outcomes: Title of session:
Feedback/comments from participants: Date:
Crèche issues: Please help me to get the session right for you by
Issues needing further action: completing the following sentences about how you feel.
Action plan: Thank you.
Completed by: It helps me when ……………………………………………………
(Hartcliffe Health and Environment Action Group and health It is difficult for me when ………………………………………
visitors from Hartcliffe and Withywood, Bristol. Reproduced I would like more of ………………………………………………
with permission.) I would like less of …………………………………………………
tages in this method: a talk is largely a one-way

BOX 12.5 Evaluation form B
communication process with little opportunity to
Title of session: assess how much people are learning or under-
Date: standing, and with only a small proportion of it
We would like your views to help us assess this likely to be remembered at the end (and still less a
session and make plans for similar sessions in the few days later).
future. All your comments will be valued and used, and Despite these limitations, talks and lectures can
treated confidentially. be valuable for several reasons. A talk can be used
Yes No Partly to introduce a health topic by giving a broad over-
1. Overall, have you found this    view of it, and this may lead people to take further
session beneficial? (please tick) action. For example, an introductory talk on first aid
Yes No Partly may lead people to enrol for a first aid course. A
2. Did the session match up to    talk may also be an important source of health
your expectations? information and awaken a critical attitude in the
3. What did you expect to gain audience, for example by drawing their attention to
from the session? issues such as traffic pollution or misleading infor-
Please comment: mation on food labels. Giving talks is also a rela-
4. Which parts of the session have tively economical way to use a health promoter’s
you found most beneficial? time, since large numbers of people can be addressed
5. Which parts of the session have at one time. In order to ensure success, the follow-
you found least beneficial? ing points need to be addressed.
6. How do you think the session
could be improved? Check the Facilities
7. Do you have any other comments If possible, visit the place where you are going to
you would like to make? give your talk and check the seating, lighting and
Please write your name here (or leave blank if you audiovisual equipment, including electric power
prefer to remain anonymous). points and extension leads. On the day of the talk,
Thank you very much for filling this in. arrive early so that you can arrange chairs, open
windows and check that the equipment is working.
Get your audiovisual equipment ready for use. If
previous level of competence in choosing you need blackout, check that you can turn the
healthy menus and cooking healthy meals. lights on and off quickly so that you do not
Monitoring students’ progress by keeping records lose rapport with the audience while they are left
of achievements can be valuable for helping them in the dark.
to see what they have achieved. If your health edu-
cation is geared towards people learning to change Make a Plan
behaviour, it can help to keep diary-type records of It can be useful to make an outline plan of your
what they ate or drank, or their physical activity whole session, indicating the sections, times and
levels. If they are learning practical creative skills, any audiovisual aids you are using. This is particu-
photographic records can help. For example, on a larly useful if you are sharing a session with a col-
course designed to help people cook and eat health- league, so that you are both clear what you are
ier food for their families, you could give them a doing. See the example in Box 12.6 and either use
single-use camera to make a pictorial record of the this as a skeleton overall plan to guide you when
dishes they cooked and their family enjoying the you make detailed notes to speak from (see section
meals. below) or it might be enough to enable you to speak
from the plan itself.
Guidelines for Giving Talks

Making and Using Notes
Giving a formal talk is often part of a health pro- It is generally best to give a talk from notes. The
moter’s work. There are considerable disadvan- more experienced you are the fewer notes you are
BOX 12.6 Plan for giving a talk

Talk on ‘Sense in the Sun – Preventing Skin Cancer’
Bloggshire Secondary School Parent–Teachers Meeting
21.10.2010: an hour at the end of the business meeting, 8.00–8.45 p.m.
SNS (school nurse) and JAS (deputy head)
AIM: to give parents basic information on risks and prevention of skin cancer
Audiovisual aids
Time Section Content PowerPoint (PP) Who
8.00 Intros Intro JAS & SNS Why we are now PP graph showing rise in skin cancer in JAS
concerned about skin cancer UK
– rising incidence?
8.05 What is skin Different types of skin cancer. How PP key points SNS
cancer? you spot it? Who is most at risk
(fair skin, sunburn, etc.)?
8.15 Prevention Key message: respect the sun – avoid Examples of sun hats, light clothing (big, SNS
exposure at hottest times, use good long-sleeved, cotton shirts, etc.).
sunscreen, cover up with sun hats Examples of sunscreen creams
and light clothing. Be a
mole-watcher
8.25 What the school Encourage the use of cover-up and Main points on PP JAS
can do? sunscreen creams in outdoor PE.
Include topic in health education
and science teaching
8.30 Summary Aim for school and parents to work PP: 3 Cs to remember: Care in the sun, SNS
together. Main points to remember: Cover up, Creams. Leaflets to take
Care in the sun, Cover up, use away
sunscreen Creams
8.35 Any questions? SNS
likely to need, unless your talk is full of technical Prepare Your Introduction
detail or likely to be taken down and quoted verba-
tim (for example, by the press). However, very few Secure the attention of your audience with your
people can give a successful talk with no notes at opening words. Some ways of doing this are:
all, and beginners may find it helpful to write out a ● State a surprising fact or an unusual quote.
talk in full before they transfer the main points ● Ask a question that has no easy answer.
to notes. ● Use a visual image to trigger interest.
If you are writing out your talk in full to begin
● Get the audience to do something active (some
with, it is useful to know that a 50-minute lecture
suggestions are discussed in the earlier section
consists of about 5000 words, allowing for pauses
on aiming for maximum involvement).
and an estimated speed of delivery of about 110
● Tell a joke, if you have the confidence to do it
words per minute. You can then try transferring the
successfully.
key points as notes to cards or paper.
Never give a talk by writing it out in full and Establish eye contact with your audience and, if
then reading it. Unless you are an exceptional orator necessary, ask them whether they can see and hear
it will sound flat and stilted. Furthermore, you will you.
find it difficult to look at your audience, because State your aim and theme at the beginning of
you will need to keep your eyes on the notes, and your talk. It should be a brief statement, not a
if you look up you are likely to lose your place. complex summary of the whole talk. For example,
say ‘I’m going to talk about the benefits of incorpo- When you ask for questions, allow people time
rating more physical activity into your life and to think; do not assume that there are to be no ques-
ways of making small changes to ensure you are tions just because one is not instantly forthcoming.
getting sufficient exercise’, but do not go into When a question is asked, it is often helpful to
detail at this point; save that for the main part of repeat it or summarise. This gives you a little time
the talk. to consider the question, and ensures that everyone
By the time you have finished the introduction, else in the audience has heard it. Never ignore or
you should have: refuse to answer a question. If you don’t know the
● established your aim and theme with the answer, admit this and ask whether anyone else in
audience the audience does. In any case, this helps to involve
● obtained their interest and commitment
the audience; you could also ask for comments on
answers: ‘Does anyone else have suggestions for
● ensured that they can hear and see you clearly.
the person who asked that question?’
Prepare the Key Points
Identify the three or four main points you wish to
Work on Your Presentation
make, and prepare your talk around each point in Important points about presentation include pace
turn. Illustrate and support your points with evi- and timing, which can mean consciously having
dence from your experience or from research, with to slow down your rate of speaking; the nervous
examples, audiovisual materials, and so on. beginner can speak too quickly. Other factors
are looking at the audience and using notes
See Chapter 11, on using and producing audiovisual
appropriately.
materials, including leaflets, handouts and DVDs.
Thorough preparation will help you to feel con-
Plan a Conclusion fident, but however nervous or inexperienced you
may feel, do not apologise for being there. For
You need to plan how you will end your talk in example, if you have been asked to give a talk about
order to avoid rambling on or trailing off. Some your work, do not say ‘I’m going to talk about the
ways of ending are: work of health visitors, but I’m afraid I’ve only been
● A very brief recapitulation (not a boring qualified for a year so there’s a lot I don’t know yet’.
repetition) of what you’ve said, such as ‘We’ve Instead, present yourself positively ‘I’m going to
now covered the basics of exercising and talk about the work of health visitors. I’ve been
lifestyle change’. qualified for a year now, and I’d like to share my
● A statement of what you hope the audience experience of the work with you’.
will do with the information you have given The way to improve presentation is practise.
them, such as ‘I hope that you can confidently Practise giving your talk out loud, or to friends or
make changes to your lifestyle to include more colleagues. Ask a trusted colleague to sit in when
exercise’. you give a talk, and to give you feedback after-
● A suggestion for further action: ‘If you’d like to
wards. It is also helpful to have your talk recorded
find out more about exercise and health please so that you can assess your own strengths and
come to see me afterwards or contact me at … weaknesses.
– giving e-mail/telephone and/or office
address’. Plan for Contingencies
● A question – ‘What small lifestyle changes can
A major fear when giving a talk is that you might
you make to include more physical activity into
lose your place or your train of thought. If this is a
your life?’
possibility, it is better to think beforehand about
● Thanking the audience for their attention and/
what you will do if it should happen. It is best to
or participation.
acknowledge that you have a problem rather than
leave an embarrassing silence. For example, say
Ask for Questions
‘Sorry, I’ve lost my place’. Remember that an audi-
If possible, include a question-and-answer session ence is likely to be friendly rather than hostile. So
in your talk. It gives you feedback, and gives the let them help by asking for time: ‘Excuse me for a
audience a chance to participate. moment while I look through my notes’.
See also section on dealing with difficulties in Chapter 13. for improvement). Not surprisingly, a large propor-
tion of patients do not comply with the advice and
Another fear is that audiovisual equipment may
treatment prescribed for them (see, for example,
not work. You cannot insure against this, so it is best
Duke 2009).
to have a contingency plan ready. For example, ‘As
There may be complex reasons for these appar-
we can’t see the sequence on PowerPoint as I’d
ent failures, but some of the cause will be the way
hoped, I’ll write the stages up on the flip-chart and
in which information, advice and instructions are
talk through them instead’, or you may wish to
given to patients. Often the circumstances are less
ensure you have a back-up, such as overhead pro-
than ideal, because patients are distressed or feeling
jector slides of the PowerPoint presentation.
unwell, and there may be little time in a busy
surgery, health centre, outpatient clinic or hospital
Improving Patient Education ward. This is all the more reason to ensure that the
best possible use is made of the time and opportuni-
Evidence suggests that patients want health infor- ties for patient education.
mation but some have difficulty in understanding All the basic communication skills discussed in
and remembering what they have been told by their Chapter 10, and the principles of helping people to
doctor, nurse or other health worker (see, for learn outlined in this chapter, are important. There
example, the research of Posma et al 2009 on older is also now a growing body of evidence in the field
patients and the difficulties they have in processing of patient education and information. See Cochrane
and remembering information). Patients also often website for various studies (http://www.cochrane.
feel dissatisfied with the communications aspect of org). Some particular principles that have been
their encounters with health professionals, and are found helpful in patient education are set out in
reluctant to ask for more information (see Jangland Box 12.7. See also Pestonjee (2000) and Osborne
et al 2009 for reasons for this and recommendations (2004).
BOX 12.7 Some principles of patient education

■ Say important things first: patients are more likely your material under these headings as you
to remember what was said at the beginning of a present it.
session, so give the most important advice and
See ‘Organise Your Material’ above.
instruction first whenever possible.
■ Stress and repeat the key points: patients are more ■ Avoid jargon and long words and sentences: if you
likely to remember what they consider to be need to use medical terms or jargon, make sure the
important, so make sure they realise what the patient understands what they mean. Never use a
important points are. For example, say: long word when a short one will do. Use short
 ‘The most important thing for you to remember sentences.
today is …’ ■ Use visual aids, leaflets, handouts and written
 ‘The one thing it’s really essential to do is …’ instructions.
Repetition of key points also helps people to remember See Chapter 11 on using communication tools.
them. ■ Avoid saying too much at once: three or four key
points are all that you can expect someone to
■ Give specific, precise advice: sometimes it is
remember from one session.
appropriate to give general guidance, but specific,
precise advice is more likely to be remembered than See ‘Ensure Relevance’ above.
vague guidance. For example, say:
■ Ensure advice is relevant and realistic in the
 ‘I advise you to lose 5 pounds in the next month’
patient’s circumstances.
rather than ‘I advise you to lose weight’.
■ Get feedback from patients to ensure that they
 ‘Try to take 30 minutes exercise every day’ rather
understand.
than ‘Take more exercise’.
■ Structure information into categories: this means See the section on asking questions and getting feedback
telling the patient headings and then categorising in Chapter 10.
EXERCISE 12.2 Skills of patient education

Work in groups of three, taking each role in turn. ■ Finally, the observer gives feedback using the
The first person takes the role of the health promoter. checklist as a guide.
She selects the topic to be taught, drawing on her own
experience, and tells the patient their medical history Communication checklist
before role-play starts.
The second person plays the patient. This patient 1. Nonverbal aspects of communication, e.g. tone of
should have one of the following sets of characteristics: voice, posture, gestures, facial expression and use
■ Intelligent,but with very limited understanding of of touch.
spoken English, no ability to read or write English 2. Sequence and structure of key points, e.g.
and no one available to translate. important things first, logical sequence,
■ Extremely worried, tense and anxious about their information in categories.
medical condition and prognosis. 3. Choice of language, e.g. appropriately simple and
■ Has some learning difficulty, finds great difficulty short, use of jargon/idioms, medical terms.
in understanding and remembering instructions 4. Two-way communication, e.g. encourage patient to
although they try hard to be cooperative. talk and express feelings, get feedback about how
The third person takes the role of the observer, using much is understood, open/closed/biased/multiple
the observer’s checklist below. questions.
Role-play the scene in which the health promoter is 5. Amount of information, e.g. too much or too
teaching the patient for 10 minutes. The observer keeps little.
time. Then give constructive feedback as follows: 6. Clarity of objective(s).
■ First, the health promoter assesses themself, saying 7. Use of repetition.
what they felt they did well, and identifying points 8. Use of emphasis to stress important points.
they feel they need to work on in the future. 9. Any assumptions made but not checked, e.g. about
■ Second, the patient describes how it felt to be the previous knowledge, facilities for carrying out
patient, identifying what the health promoter did instructions, willingness to comply.
or said which made them feel at ease/put down/ 10. Anything else?
anxious/reassured/more confused, and so on.
Exercise 12.2 is designed to help you practise the and step-by-step progress are needed. Confidence
skills of patient education and supplements the building is as important a part of the health educa-
basic communication skills outlined in Chapter 10. tor’s role as developing practical skills.
Another useful way of learning to improve com- In order to develop clients’ ability to perform
munication skills is to record and then analyse an a skilled task, a three-stage approach is most
interview with a patient. effective:
Stage 1. Demonstrate.
Teaching Practical Skills Stage 2. Rehearse.
for Health Stage 3. Practise.
Health promoters are often called upon to teach Clients will be watching and listening in stage 1, but
practical skills, such as relaxation or keep-fit exer- they become actively involved in doing in stages 2
cises, how to bath a baby or change a nappy, and and 3.
how to give an injection or test urine. It may be useful to begin by using a dummy, for
Teaching a skill is not just about giving the client example when teaching safe lifting techniques, or
information and teaching new practical skills. It is to use an orange instead of a person when teaching
also necessary to pay attention to what clients feel. injection techniques. As skills develop, the tech-
If people are afraid to do something because they niques can be tried in real-life situations (lifting
are worried about looking foolish or doing it incor- people, for example) and perhaps under more
rectly, they are unlikely to succeed: encouragement difficult circumstances.
Individual learners need to progress at their own factors that help and hinder the learning process.
pace and build up confidence at each stage. For this You may find it helpful to use informal learning
reason teaching practical skills needs time and contracts.
patience, but it is worth the investment to get the ■ Giving talks on health topics requires detailed
right skills programme from the beginning. People planning, preparation and practise.
who have lost confidence in their ability to do ■ You can help patients to understand and remember
something are sometimes more difficult to help more if you take account of some key principles of
than a new learner. patient education.
■ Use a three-stage approach of demonstration,
rehearsal and practice when you are teaching
PRACTICE POINTS
practical health-related skills.
■ To be successful in health education with clients
you need to understand principles of learning and
References
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principles of teaching and learning 75(2): 199–204. patients, relatives and professionals.
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and Bartlett. Involving students in learning and biomedcentral.com/1472-6955/8/1.
Bastable SB 2004 Essentials of patient health promotion processes Rogers J 2001 Adults learning, 4th edn.
education. Sudbury, Jones and – clarifying why? what? and how? Buckingham, Open University
Bartlett. Promotion & Education 12(3–4): Press.
Duke S-AS, Colagiuri S, Colagiuri R 150–156. Suter PM, Suter WN 2008 Timeless
2009 Individual patient education Osborne H 2004 Health literacy for principles of learning: a solid
for people with type 2 diabetes A–Z: practical ways to foundation for enhancing chronic
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10.1002/14651858.CD005268.pub2. of patient education. Springhouse,
Jangland E, Gunningberg L, Carlsson Springhouse Corporation. Website
M 2009 Patients’ and relatives’ Posma ER, van Weert JCM, Jansen J, http://www.cochrane.org
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177
Chapter 13
Working with groups
Summary
Chapter Contents
This chapter is about working with clients in groups
Types of groups 178 and begins by discussing the range of groups in health
promotion, potential benefits of group work and
Potential benefits of group work 178
when it is appropriate to use it as an approach. Group
When to use group work 178 leadership styles and responsibilities and individual
group behaviour are considered. The last part of the
Group leadership 180
chapter focuses on the competencies needed for
Group behaviour 182 working successfully with people in groups, including
the practicalities and skills of setting up a group,
Setting up a group 183
getting groups established, discussion skills and
Getting groups going 185 dealing with difficulties. Exercises focus on identifying
Discussion skills 186 the benefits of joining a group, looking at your
leadership style and planning a group meeting.
Dealing with difficulties 188
Health promoters work with many different kinds

of groups in a variety of settings. Working with
groups of colleagues is considered in Chapter 9; in
this chapter, the focus is on the health promoter’s
work with groups of clients, but many of the skills
discussed in Chapter 9 (such as coordination, team-
work and working effectively in meetings and
committees) may also apply when working with
clients.
See Chapter 9.
Group work encourages clients to be active par-

ticipants in their own health issues and with their
communities. Many of the groups with which
health promoters are involved will already exist,
where members have come together for a common
purpose and health issues form part, or the whole,
of the agenda. The role of the health promoter may
vary widely, from leading a one-off session to facili- task has changed to campaigning. A new group is
tating the development of a new group, or leading required for the new task.
a group with a defined lifespan. Whatever the role, The type of task will determine the most effective
competencies in group work are needed. Leading size for the group; for example, educational groups
therapeutic groups are excluded from the discus- may be larger than support groups.
sions in this chapter. Therapy requires in-depth pro- Different kinds of groups may also require the
fessional training in a range of possible approaches, health promoter to take on different roles, and use
outside the scope of this book, but see Hogg & different skills. Leading or facilitating groups
Scott Tindale (2002) Buckroyd & Rother (2007) and requires special skills and methods; later in this
Bertram (2008) for discussion on therapeutic groups. chapter group leadership and the skills you need to
be effective as a group leader are discussed.
Types of Groups
Potential Benefits of Group Work
Groups are formed for a variety of purposes and are
not simply a random collection of individuals. It is important that a group leader or facilitator
Members generally have a sense of shared identity, considers the benefits for the individual client of
common objectives, defined membership criteria using a group as a medium for support (Stock
and their own particular ways of working. The term Whitaker 2001). The process of being part of a group
group work can be applied to a range of activities is often as important as the intended outcome of the
such as group therapy, social action or self-help. group; for example, a young parent may gain
Groups in the context of health promotion are friends and social skills by being part of a parenting
usually formed for one or more of the following group as well as learning parenting skills.
purposes. In addition to thinking of potential benefits for
For raising awareness. To increase members’ inter- the group as a whole, the group facilitator needs to
est in, and awareness of, health issues through think about which benefits are relevant to individ-
group discussion. This may be a group already in ual group members. Different group members may
existence, such as a women’s group, which may benefit in different ways. Exercise 13.1 is designed
agree to discuss a health issue. to help you think about what joining a group could
For mutual support. To support members in diffi- mean to a client.
cult decision making, to help each other to cope
with shared health problems/disabilities, or to
change a health-damaging behaviour. Examples are
When to Use Group Work
self-help groups such as patients’ associations and
Health promoters may be unsure about when it is
Alcoholics Anonymous.
appropriate to use a group work approach to health
For social action. To use collective power to cam-
promotion. Group work is appropriate when your
paign for social change, for example tackling a local
plans fulfill the following criteria:
problem of drug misuse, housing standards or com-
munity facilities. See also Chapter 5, section on deciding the best way of
For education. To impart skills, offer information achieving your aims.
and sometimes to prepare members for specific life
events, for example becoming a parent. ● You have looked critically at what other health
For group counselling. To help members to find promotion opportunities exist, and you have
solutions through exploring a shared problem with concluded that group work is needed to meet the
a counsellor, for example a group of menopausal particular needs of specific groups of people.
women. ● You have evidence that group work is effective
Being clear about the purpose of a group is for this particular client group.
important. Confusion can result if the tasks of a ● You are going to be working with a defined
group are changed, especially if this means that group of people over a period of time, which
individual members have to adopt different roles. will allow the group to build up trust and be
For example, an individual will have difficulty if able to help each other, for example a group of
she attends a group to obtain support, and finds the teenage mothers, a self-help group of patients
Chapter 13 Working with groups 179
● You are planning to work with people who are

EXERCISE 13.1 How can joining a group
promote health? already in a close small group, and possibly
already used to group work, for example a
Think of a group that you have: group of young people who are in a residential
■ set up in the past, or drug rehabilitation setting.
■ intend to establish in the future, or ● You are establishing a connection with a
■ belonged to yourself. number of people who have a common interest,
Consider the list of potential benefits below. Which ones and wish to develop an equal and respectful
could apply to members of your group? partnership with them, for example a group of
Trying out new behaviours that are better for the  people with mental health problems who have
group members or other people they have recently moved into a group home.
contact with. ● You want to work with a particular ethnic
Gaining new health knowledge, becoming better  minority community but you do not come from
informed. that group yourself and are faced with issues of
Learning new ways of doing things and acquiring  differences in culture and language. In this
new skills for health. case, it could be helpful to run a group to look
Finding better ways of coping with everyday life.  at health issues in partnership with a link
Feeling less isolated, reducing the sense of being  worker or health advocate who can offer
alone with an illness or problem or that nobody culturally sensitive help and skills in translation
else understands. and interpretation.
Developing more confidence, with group members 
There are times when it may not be advisable to
having a more positive view of themselves.
embark on group work, or to continue to run an
Group members recognising that they can make 
existing group. These may include situations when:
changes, they can see new possibilities.
Revising previously held assumptions group  ● You have not consulted with prospective
members had about themselves and/or others; clients to establish their needs.
they think differently about themselves and ● Group members are from such a diverse range
others. of backgrounds that they have little in common
Developing an understanding, or a fuller and more  and feel uncomfortable with one another.
accurate understanding, of how past experiences ● The cultural or psychosocial background of the
have, until now, influenced group members. group will make it difficult for them to adapt to
Feeling able to work with other people to take  group work.
action about a health issue group members feel ● The group will meet only once or twice, which
strongly about. means that people will not have long enough to
Can you think of any other benefits? get to know and trust one another.
(This exercise is adjusted from Stock Whitaker 2001.) ● The membership of a group is not stable and
people are constantly leaving or joining.
● Your aim is solely to transmit information, so
that a talk with questions and answers would
who are recovering after heart attacks, or be better.
people who have been diagnosed as HIV ● The aim of the group is to encourage a change
positive. towards a healthier lifestyle but the people
● You have access to a comfortable, private and concerned do not have the opportunity to make
relaxed environment in which to run the group, changes because of lack of money, skills,
for example a community centre. support or facilities.
● You have access to support and supervision in ● You do not have suitable accommodation for
order to provide you with assistance when you meetings; for example, you only have available
need it and help you to develop your group a large, tiered lecture theatre.
work. ● You do not yet have the competencies to
In some circumstances group work may be particu- facilitate group work, or access to the necessary
larly helpful. Examples are: training and support.
Group Leadership ability to confront difficult issues and resolve con-

flict using a problem-solving approach.
Two aspects of group leadership are useful to con- See Chapter 9, section on understanding conflict and
sider. One is your leadership style and the other is Exercise 9.3 on identifying your conflict resolution style.
your responsibilities as a group leader.
The strength of this style is that clients learn to
trust their own judgements and at the same time to
Leadership Style appreciate other people’s rights and opinions.
It is important that all the members of the group are The weaknesses of this style may be that strong
agreed on who is the leader, and support the leader feelings are uncovered and distress experienced by
in this role. The leadership style needs to be com- the client and yourself, which might be difficult to
patible with the group members, especially if the manage. Also, clients who are used to being told
group has to work together to complete complex what to do may feel confused and dissatisfied
tasks. For example, a group of highly motivated because they are not receiving advice and direction.
and trained professionals will work best with a They will need to have the approach explained to
leader who encourages participation and shared them and be given suitable learning experiences to
decision making. It is essential for leaders to be show them that it works.
aware of which style members prefer, and to Group leaders can operate somewhere between
develop the ability to adjust their style if the situa- the two extremes, providing some authoritative
tion demands it. leadership while also encouraging a degree of par-
A key dimension of leadership style is where the ticipation. Successful group leadership depends on
leader stands on a continuum from authoritarian to a variety of factors such as:
participative. ● The leader’s preferred style of operating and
personality. For example, if you have been used
authoritarian participative
to being perceived as the expert, with the
An authoritarian style is directive, with the authority of professional knowledge that you
group leader acting as a source of expertise. If you want to pass on, you will probably feel (and
adopt this approach, you rely on your status, cred- look) uncomfortable if you try to switch to a
ibility and expertise to ensure acceptance of your facilitator style without sufficient training, and
views and leadership role. this may produce tension in the group.
The strength of this style is that children and vul- ● The group members’ preferred style of
nerable people (such as those who are sick or dis- leadership in the specific circumstances of the
tressed) may feel secure, reassured and protected group. For example, if group members are low
from harm. in confidence, they may need you to be more
The weaknesses of this style are that clients may authoritarian to start with, so that they feel
become fearful, anxious and reluctant to take inde- secure. You can then gradually encourage
pendent action; it does not develop their ability to participation and adopt a more facilitative style
take responsibility for their own decisions and as members learn to trust you and each other,
actions. Furthermore, clients may respond by rebel- and feel confident enough to join in.
ling and rejecting your guidance. ● The group’s objectives and tasks. For example,
A participative style involves shifting power a group that has the objective of learning new
from the group leader so that it is shared between skills (such as an exercise class) will need a
the leader and the group members. This means more authoritarian leader who will tell them
using all the skills and knowledge of the group how to do the exercises properly, whereas a
members as well as the leader, who is more likely group of parents in a support group that aims
to choose the title of facilitator. As a facilitator, you to help them recover from the death of a child
will need to show warmth and empathy, encourage will need a facilitator to help members to
group members to express their feelings and express and work through their grief.
provide counsel and encouragement. You will need ● The wider environment, such as the culture of
to be tolerant of different viewpoints, showing fair- the group members, and of the organisations
ness and impartiality. You will need skills and they belong to. For example, the cultural norm
of some ethnic minorities may be passive, and clients may feel neither nurtured nor secure. Group
they may not only lack confidence about active leaders may need to build up their own assertive-
participation in groups but may also perceive it ness skills in order to avoid an overly permissive
as inappropriate. approach. Undertake Exercise 13.2 to determine
You need to consider these factors and how they your leadership style.
might be modified in order that the group achieves
its purpose. The easiest thing to modify in the short
term should be your own style, but in the long term Leadership Responsibilities
it may also be possible to make other changes, for The responsibilities of group leaders will depend
example to develop the group members’ confidence on the role they take; for example, whether they are
so that they are willing to take on more responsibil- responsible for the practical organisation such as
ity and participation. booking a venue. But whatever the role, a leader’s
See Chapter 3, section on analysing your aims and responsibilities may include:
values: five approaches. ● Helping members to identify and clarify their
interests and needs, and what they would like
The participative style fits best with the self-
to gain from the group in the short and long
empowering client-centred approach to health pro-
term.
motion. However, some health promoters will have
● Helping to develop a relaxed atmosphere in
been trained in an authoritarian style and will have
which members feel able to be open and
modelled themselves on this experience. If this is
trusting with each other, and able to participate
true in your case, you will need to learn how to
freely.
work in a participative style in order to become
more effective in empowering your clients. ● Offering expertise to the group on the
Finally, a participative style must be distin- understanding that members are free to accept
guished from a permissive style. A permissive style or reject the offer.
lets clients come to their own conclusions and aims ● Accepting and valuing all contributions from
to avoid conflict and keep everyone happy. Helping group members.
the clients to enjoy the experience is more important But it is not only the group leader who has respon-
to the leader than achieving the goals of the group. sibilities: group members have them too. They may
Difficulties and conflict are not confronted and the include:
EXERCISE 13.2 Looking at your leadership style

The following questions aim to help you to examine your own leadership style. Put a tick in the appropriate box.
Never Sometimes Usually Always
1. Do your clients say what they feel?    
2. Do clients finish what they are saying before you respond?    
3. Do you think you are able to see things from your clients’ point of    
view?
4. Do clients disagree with you?    
5. Do you explore with your clients the consequences of alternative    
actions?
6. Do you help clients to discuss painful memories or sensitive issues?    
7. Do you share all the information at your disposal?    
8. Do you help clients to discover their own strengths?    
9. Do you respect your clients’ right to reject your advice?    
What leadership style – authoritarian, participative or permissive – do you think you usually use?
What influences led you to develop this style?
Can you identify any advantages in using alternative leadership styles in your work?
Can you identify any aspects of your leadership style that you would like to change?
● Participating in clarifying the aims of the 4. Performing. The group is fully effective at this
group. stage and is able to concentrate on its tasks.
● Choosing whether and how much to participate. When the developmental process fails in some
● Identifying personal goals and concerns. way, attempts to sabotage the group may occur. It
● Deciding which challenges and risks they are
is thus worth investing time and effort to help new
prepared to take. For example, how much are groups to develop successfully.
they prepared to expose their own weaknesses Many groups have a limited life, meeting for a
and vulnerability to other people in the group? set number of sessions or until a particular task has
been completed. At the end of a group’s life, it may
be helpful to have a final session, which could give
group members an opportunity to express their
Group Behaviour appreciation and perhaps arrange a follow-up or
reunion.
Health promoters will be able to work with a group
more effectively if they are aware of the group
dynamics and the ways in which people are likely Group Members’ Roles
to behave when they come together in groups. An early study established the characteristics of
There are three aspects of group behaviour that you members of teams identifying that a mix of nine
may find particularly useful: the pattern of behav- roles is needed for full effectiveness (Belbin 1981)
iour that usually develops in a group’s life, the dif- These roles are also relevant to a group’s effective-
ferent roles group members may perform and the ness and are outlined in Box 13.1.
concept of hidden agendas. At different times, each group member may play
a variety of these roles, and most people have per-
sonal characteristics which might result in more
Group Development affinity with a particular role. If one or more of
Groups tend to show a particular pattern of behav- these roles is lacking, a member or leader can help
iour as they mature and develop. An early and
much quoted study characterised a group develop-
mental process in to four stages (Tuckman 1965):
1. Forming. The group is forming. People meet BOX 13.1 Roles needed for effective groups
each other, and get to know one another, with indi- and teams
viduals establishing their own identity and role The Coordinator – clarifies goals, promotes decision
within the group. The group’s purpose and way of making, delegates well to enable the group to
working are established. work effectively.
2. Storming. Most groups go through a conflict The Shaper – is action oriented and encourages the
stage when the leadership and ways in which the group to get on with its tasks.
group is working are challenged. For example, The Plant – is the creative source of ideas and
people may question how things are being done proposals.
and what the leader’s role is, and may get into The Monitor/Evaluator – is good at analysing and
heated discussions with each other. This can be a criticising.
difficult period for both leader and members, but it The Resource Investigator – has a good network of
is a vital stage in the group’s maturing process, contacts and liaises with other people and
rather like the period of rebelling and questioning agencies.
during adolescence. Successful handling of this The Company Worker – is good at organising and
period leads to the development of open communi- administration.
cation, trust and shared responsibility for achieving The Team Worker – supports the members of the
the purposes of the group. group and is a good listener.
The Specialist – provides specialist knowledge and
See Chapter 9, section on understanding conflict.
skills.
3. Norming. At this stage the group settles down, The Finisher – contributes foresight and perseverance
with the norms and accepted practices of the group to ensure that the group completes its tasks.
established.
to make a group more successful by consciously ● Are you aiming to satisfy your own needs or
adopting a new role, or encouraging other team your clients’ needs? (Your reasons can include
members to adjust their roles. both, but it is helpful to distinguish between
them.)
Hidden Agendas
Who will the members be?
People will have their own individual reasons for
joining a group, which may be in addition to, or ● Will the members be referred (from their GP,
instead of, the reason expected. For example, a for example), will they be coerced into joining
woman may attend a women’s health group because or will membership be entirely voluntary?
she is lonely and sees the group as a way of meeting ● Have you given everyone an equal opportunity
people; she has not joined because she is particu- to join (such as ensuring facilities for
larly interested in health issues. Or a group member wheelchairs, disabled toilets, signing for those
may seek a prominent position in a group, such as hard of hearing, hearing loops, translation into
being the Chair or Secretary, to fulfill their need to appropriate minority languages)? Have you
feel valued and useful; they may or may not also be made provision for people to let you know of
committed to the work itself and the aims of the any special needs?
group. In these examples, fulfilling these personal ● How will you identify the potential members
objectives are hidden agendas. of your group – from individuals requesting a
Most people bring their own hidden agendas to group, from local or national registers, from
groups, in addition to the agreed group objectives; people with shared characteristics (such as age,
these commonly include meeting the need for social sex, lifestyle, culture, job, health concern), or by
contact, or making a particular alliance. Members other means?
will work together best when there is communica- ● How will you recruit your members? Do you
tion about individual objectives or agendas and need to advertise?
agreement about shared objectives. Otherwise ● How many members do you aim to have?
members may promote their own interests at the What is the ideal number, bearing in mind the
expense of the group. You will be more effective as purpose of the group and any constraints
a group leader if you are aware of the hidden imposed by your location?
agendas in the group and can find ways of dealing
with them.
What are the group’s aims and objectives?
● Are these within the realistic abilities of
Setting up a Group yourself and the members?
● Can all the potential membership understand
Planning and preparation are essential for success- them?
ful group work. The sections below take you step
● Are you clear about your own objectives in
by step through the thinking and planning you
setting up the group, and whether these are
need to do when setting up a group.
different from the members’ objectives?
● Are all members clear about their individual
Why are you proposing to run the group? objectives, i.e. the specific outcomes they hope
to achieve through attending the group?
● Are you reacting to a demand from clients,
other professionals, a community or your own
observations?
Where will the group meet?
● Are you trying to develop your health promo ● Is the location appropriate? For example, a
tion role and see this group as a way of health centre or hospital could appear clinical
progressing? and cold and remind people of illness. Neutral
● Are you aiming to provide advice and support, territory, such as a room in a community centre,
to supply information or to help people to or someone’s house, may be more relaxing and
change health-related behaviour? inviting.
der
Lea
A B
Fig. 13.1 (A) Seating in a circle – best for group work; (B) traditional seating in rows – not suitable for group work.
● What is the seating like? If you are aiming for familiar with the equipment and confident you
participative group work, seating people in a can operate it? Does the equipment have to be
circle is best (see Fig. 13.1), with physical booked in advance? If so, are you familiar with
barriers to communication such as tables or the booking system?
desks removed. Can you put chairs in a circle, ● Do you need any additional resources such as
where all group members can see each DVDs, leaflets, posters, books, outside
other? speakers? If so, have you made all the
● What are the facilities like? Is there enough necessary arrangements in advance?
space for the activities you plan? Is the floor ● Do you need to pay for anything? If so, have
covering suitable for the purpose? Is the you identified a source of funding (for example,
temperature suitable and adjustable if a charge to the group members or a sponsor)?
necessary? Are the facilities adequate for the
purpose (for example, access for pushchairs,
toilets, catering facilities, washing/shower When will the group meet?
rooms, crèche)? Are there facilities for people
with special needs (for example, wide access ● Is the time you have chosen the best one for the
for wheelchairs, disabled toilets, hearing loops, clients, or have you chosen it to suit yourself?
signs in minority languages)? ● Does the length of meetings suit members and
● Is access good? Is the venue accessible by local take into account their other commitments?
transport? Do you have transport for members ● Have you consulted potential members about
who cannot manage on public transport? Are timing and tried to satisfy the majority?
parking arrangements satisfactory?
● What are the security arrangements? Where the
How will the group be run?
fire extinguishers and what is the fire drill? In
case of an emergency, who do you contact? Do ● Will it be a self-help group and directed by the
you need insurance cover? members, or led by a health professional?
● To what extent will the structure be flexible and
What resources do you need? the content negotiable?
● Will the group be open (anyone can join at any
● Do you need any special equipment, for time) or will there be restrictions on admitting
example audiovisual equipment? Are you new members once the group has started?
How will the group be evaluated? Getting to Know Each Other

● At the end of each meeting? At the end of the Knowing each person’s name and something about
group? Or both? them is the first step towards constructive group
work because it helps them to feel valued as a
See also Chapter 12, section on evaluation, feedback and member of the group, and is the beginning of open-
assessment. ness and trust between members.
● Verbally, or in writing, or both? How will you
There are many ways of going about this, some
ask questions in order to obtain accurate of which are as follows.
feedback from members (for example, by
providing opportunities for anonymous Introduction in pairs
feedback)?
● How will you know that the group, individual
Ask each person to sit next to someone they have
and your own objectives have been achieved? not met before. One person in each pair then inter-
views their partner. After a few minutes (the leader
● Were there any unplanned outcomes of the
keeps the time) the partners swap roles. Then, in
group? Were these desirable or undesirable?
turn, each member of the group introduces their
What caused them?
partner by name and says something about them.
● What have you learned? What would you do
You may like to remind people that no one has to
differently next time? answer any questions if they do not wish to.
(See Doel 2006 for more details in setting up a group The leader could also suggest appropriate ques-
and group work in general.) tions. For example, in groups for prospective
parents the leader could suggest that partners find
out if this is the first baby, where the mother goes
Getting Groups Going for antenatal check-ups or where she is booked to
have her baby.
Some people may feel nervous about going to a
group meeting for the first time, especially if they
are unlikely to know other members. The initial Name games
task for the group leader is to help people to feel
Group members sit in a circle and you, the leader,
at ease.
take an object, such as a pen, and hand it to the
See also Chapter 5 on the basic planning and evaluation person on your left, saying ‘My name is A and this
process. is a pen’. You ask the person who now holds the
pen to say ‘My name is B and A says that this is a
pen’. B then passes the pen to the person on his left,
Before the First Meeting who says ‘My name is C and B says that A says that
If you know in advance who is coming to a group this is a pen’. This continues until the pen gets back
meeting, it may be helpful and welcoming to to the beginning. If group members forget some-
confirm by letter or telephone that you are expect- one’s name the rest of the group can prompt them.
ing them, and the time and place. If anyone has let This helps to establish a cooperative and supportive
you know they have special needs, contact them in atmosphere as well as helping people to learn each
advance to discuss their needs and let them know other’s names. Any tension and embarrassment is
what facilities will be available. relieved by laughing and tension is effectively
broken.
At subsequent group meetings, it is often helpful
On Arrival
to do a quick round of names at the beginning, for
It helps if clients can be greeted personally, intro- example ‘Who would like to have a shot at naming
duced to other people or given something to do: every member of the group?’ or ‘I’m going to try to
‘There are some books and leaflets on the table if see if I can remember everyone’s name’.
you’d like to look at them until everyone has You might like to set the tone by suggesting how
arrived’. Ensure that anyone with special needs has people are addressed, by first names or more for-
appropriate facilities and assistance. mally. The important thing is to encourage people
to use whatever feels comfortable: ‘My name is Ann group’s life, members need the opportunity to
Jones, and I’m happy for you to call me Ann’. explore their expectations, and reach agreement
about issues such as the following:
● How members are expected to behave in the
Sharing initial feelings and expectations
group.
People may be helped to relax if they know that ● Are any rules and sanctions to be set, for
others also feel nervous or shy. So ask ‘What did example about nonattendance at group
you feel about coming here today? Did anyone feel meetings or whether members can join in if
nervous? Did anyone almost not come?’ This can they arrive late?
open the way for people to express their anxieties. ● What is confidential to the group?
You can also encourage them to say why they have
● Can new members join at any time, or is the
come to the meeting and what they expect to gain
group closed to new membership?
from it. It might help to ask members to complete
● How will the leader and the members exercise
a checklist, ticking statements that are true for them.
Such statements could include: control in the group?
● Who has responsibility for the practical aspects
● I’m worried I won’t have anything to say.
of running the group, such as bringing
● I’m afraid I’ll talk too much.
refreshments along or booking the room?
● I’m worried I’ll make a fool of myself.
For example, in a self-help group, mutual rights
● I’ll be too embarrassed to join in.
and responsibilities will be agreed on the basis of
● I’m afraid I might get upset. equality of leader and clients, but in reality the
● I’m concerned I may be bored. power balance will not be completely equal and a
● I want to meet other people in the same contract will help with power sharing. In a counsel-
situation. ling group the power of the counsellor is much
● I enjoy talking to others. greater than that of the clients and the leader has a
● I enjoy a good debate. duty to respect the members and to promote their
● I want to get out of the house. autonomy.
● I want to go somewhere different.
● I enjoy listening to other people.
Discussion Skills
People can then compare their list with that of one
or two other people, and then it may be helpful to A discussion may not happen just by putting
share what has been discovered with the whole a group of people together and saying ‘Let’s dis
group. cuss …’. Discussion needs planning and prepar
ation, and there are many ways of triggering it off
and providing structures that will help everyone
Setting Ground Rules
to participate.
People joining a group will have different expecta-
tions and assumptions about how the group will
Trigger Materials
run. Problems can arise if these are not brought out
in the open and clarified at the beginning. For Discussion can be triggered by providing a focus,
example, people may assume that what they say in preferably a controversial one. This can simply be
a group will be treated confidentially, and then be a question ‘What do you think about the call to ban
upset if they find that another member did not child-in-car smoking?’, but it might also be a leaflet,
realise this and had discussed the issue elsewhere; a poster, a health promotion campaign film or an
or some members might expect the group leader item in a newspaper or magazine (‘What do you
to take all the responsibility for organising the think the makers of this alcoholic drink are trying
group, and may feel let down if they later discover to convey in this advertisement?’). Choose some-
that the leader expects them to do some of the thing that people are likely to have strong views
work. about.
To prevent these difficulties, it is often helpful to Some health promotion campaign films are
establish a set of ground rules. Early on in the specially made as trigger materials, presenting
situations for people to talk about. Helpful notes for ● No comments on anybody’s contribution until
group leaders often accompany such campaign the full round is completed (no discussions,
films. interpretation, not even ‘I think that too’
remarks).
● Anyone can choose not to participate. Give
Brainstorms/Think Sessions
permission, clearly and emphatically, that
Brainstorming is a useful way to open up a subject anyone who does not want to make a statement
and collect everyone’s ideas. Ask an open question can just say pass. This is very important for
to which there is no single right answer, such as reinforcing the principle of voluntary
‘Why do some young people binge drink?’ or ‘What participation.
do you feel you need to know before your baby is ● It does not matter if two or more people in the
born?’ Accept every suggestion, without comment round say the same thing. People should stick
or criticism, and write them down in a list on a flip- to saying what they had intended even if
chart or blackboard. Ask the group not to start dis- someone else has said it already; they do not
cussing the ideas until everybody has finished. You have to think of something different.
can make your own suggestions and write them
Rounds are also useful ways of beginning and
down along with others.
ending sessions. For example:
In this way all members’ contributions are
equally valued and everyone has a chance to par- ‘One thing I’ve put into practice since last week
ticipate. Encourage shy members by asking ‘Any- is …’
thing else?’ and allowing silent pauses while people ‘The main thing I’ve got from today’s session
think. is …’
Then you can set the group to work by asking ‘One thing I’m going to find out by next time
them to put the ideas into categories, and to identify we meet is …’
the key features of each category. For example, It is also a useful way of getting feedback. For
people might categorise reasons for binge drinking example:
into a constructive category: ‘It helps me to socialise’ ‘One thing I really liked about today’s session
or ‘It helps me to relax, to feel good’, and an escape was …’
category: ‘I can forget my problems’ or ‘It stops me ‘One thing I didn’t like about today’s session
from feeling upset’. was …’
‘One thing I wish we’d done is …’
Rounds
Buzz Groups
A round is a way of giving everyone an equal
chance to participate. You invite each group member Buzz groups are small groups of two to six people
in turn round the circle to make a brief statement. who discuss questions or topics for short periods,
You might like to start the round yourself or to join usually about 10 minutes. It is especially useful for
in when your turn comes in the circle. For example, large groups to be divided up in this way, as it gives
ask everyone to make a brief statement about one everyone more chance to talk. Form the groups first
of the following: of all, then say what you would like each one to do,
‘My first feelings when I knew I was pregnant such as ‘Make a list of the times when you want a
were …’ cigarette’ or ‘Talk about the things you find helpful
when you feel stressed’, and how long they have in
‘What I think about jogging is …’
which to do it. If you want people to share ideas
‘The main reason why I can’t lose weight is …’ with the rest of the group as a whole afterwards, it
‘The thing that has helped me most in my may be helpful to provide large sheets of paper and
efforts to give up smoking is …’ felt-tip pens, so that feedback posters can be put up
There are four essential rules for successful rounds, for everyone to see and discuss.
which must be explained and gently enforced if
necessary. These are: Safe Revelations
● No interruptions until each person has finished Sometimes people may hesitate or refuse to say
his statement. what they really feel for fear of looking silly, being
embarrassed or getting upset. One way of overcom- have come along, but I wasn’t expecting such
ing this is to give everyone a piece of paper and ask numbers, so we may be a bit crowded this week’.
them to write down, for example, what their biggest Also share your plans for dealing with the disaster
worries are, or what they really want to know. All (‘I’m going to try to get a bigger room next time’ …
the papers are then folded and put in a receptacle, ‘I’m going to start 10 minutes late’). Sharing the
such as a waste-paper basket or a shopping bag. problem and enlisting cooperation can have the
Each person in turn picks out one piece of paper positive benefit of encouraging mutual support; not
and reads aloud what is written on it. Tell people sharing it can leave your group feeling angry.
not to say if they happen to pick out their own
piece of paper, and that, of course, nobody needs to
identify themselves as the author of any of the Distractions
statements.
The aim is to find out the concerns of the group Distractions can take many forms: noises outside
members in the security of anonymity. Make sure the room (such as road works), noises inside the
that everyone listens and does not comment until room (such as crying babies, coughing), people
all the papers have been read out. Then you can coming in late or leaving early, or interruptions.
discuss what was discovered. Distractions can also be caused by group members
themselves, for example by someone becoming
very angry or upset.
As a rule, there are three choices for you as group
Dealing with Difficulties leader:
Acknowledge the potential difficulties of running a ● Ignore them. This is seldom a good idea, as it
group and work out strategies for coping should leaves people wondering whether you are
the problem actually arise. Some common problems going to do anything, and this in itself is a
and possible strategies for coping are as follows. distraction.
● Acknowledge and accept them. This is
generally best with things you cannot change ‘I
Silence know the traffic is really noisy, but there’s
Silence can be useful; it can be time that group nothing we can do about it, so I think we’ll just
members need to think. Silence often does not feel have to put up with it this time and I will find
as threatening to group members as it may do to a different room/venue for future meetings’.
the facilitator; however, you may find it helpful to: ● Do something about them. It is preferable to
● Run a group with a partner, so that you can involve the group in the decision: ‘As so many
help each other out if either of you gets stuck. of you found it difficult to get here by 2 o’clock,
● Ensure thorough preparation, so that you have shall we start at 2.15 next week?’ or ‘Do you
planned activities and questions. Write down a think it would be helpful if you took it in turns
plan and a list of questions to ask (such as at to look after the babies in the next room?’
the end of showing a DVD). If someone is showing emotion, such as crying,
● Have an additional activity ready to use if the acknowledge it: ‘I can see that you’re upset’, and
reason for the discussion closing down is that offer reassurance that it is OK to show emotion:
what you have planned does not seem to be ‘There’s no need to be embarrassed … we don’t
working. mind if you cry …’, and offer the opportunity to
talk about it: ‘Would you like to tell us what is
upsetting you?’ or to take some time away from the
Disasters
group, accompanied by you or someone else: ‘Shall
Unexpected disasters include such things as arriv- we go outside for a few minutes?’ Do not put any
ing late, or finding that too few or too many people pressure on people in distress. Help them to do
have turned up. There is no blueprint strategy to what they want to do, whether it is cry, talk, keep
cope with the unexpected, but it will help if you silent, stay, leave or be by themselves. But do not
acknowledge what has happened and share it with ignore a show of emotion; ignoring it will only
your group: ‘I’m delighted that so many of you cause tension and embarrassment.
Difficult Behaviour ● Finally, it may be necessary to confront a person

who talks too much, but not in front of the rest of
How group members behave can pose difficulties the group. For example, you could say: ‘I’ve
for the leader. There are two broad categories of noticed that you contribute a great deal to the
difficult behaviour: nonparticipation and talking group discussions. That makes me concerned
too much. The latter category takes many forms: the about whether other people are getting enough
person who dominates and always responds with chance to talk. I’d like to suggest that you keep
the answers and prevents other people contribut- your comments to just a couple of sentences.
ing, people who launch into long stories, people Would you feel OK about doing that?’
who interrupt, people who talk off the point, people
who always disagree and people who always crack Exercise 13.3 offers you the opportunity to apply all
jokes. Note that people often change their behav- the points above when planning a group meeting.
iour as they get to know others and feel more com- Case study 13.1 is an example of good practice in
fortable in a group, but here are some points about the use of group work.
dealing with people who talk too much, and about
encouraging quiet members to engage. PRACTICE POINTS
● Think about why dominant people are ■ In health promotion, groups are useful for raising
behaving like this. Are they nervous, threatened awareness of health issues, mutual support, social
or worried? Are they desperately in need of action, education and group counselling.
attention? If you can deal with the underlying ■ Group work covers a wide range of activities and
cause, the situation is likely to improve. has a number of potential benefits for individual
● Get people to work in pairs or small groups, group members.
which can help quiet members to join in and ■ Group work is not always the most appropriate
give others a break from the constant talker. health promotion method to use; you need to be
● Use structures in your discussion such as sure that it is right for your particular clients and
rounds, or make a point of asking for other circumstances.
people’s opinions: ‘Would someone else like to ■ You need to develop skills of group leadership,
say what he thinks?’ or ‘Would you like to give appreciate the range of leadership styles and
us your opinion, Ann?’ understand the roles and responsibilities of both
EXERCISE 13.3 Planning a group meeting

1. Identify a health promotion opportunity that you Complete the following:
have encountered or are likely to encounter, where At the end of the first meeting, each group member
informal group work would be appropriate will:
1.………….
For example, this could be a group of food handlers, a
2.………….
pre-retirement group, an antenatal group, a group of
3.………….
patients in hospital recovering from a heart attack, a
etc. ………..
stop-smoking group or a group for healthy eating and
weight control. 2. Make a plan for what you will do
Assume that your group consists of about 12 people
■ As people start to arrive.
who do not know each other, and that this is the first of
■ To get people to become acquainted with each
several meetings.
other.
What do you think would be the best place and time
■ In the main part of the group meeting.
to meet, and the best physical features of the
■ To round off the meeting at the end.
meeting room?
■ To evaluate whether you have achieved the
What are your aims for the first meeting?
objectives you set.
What are your objectives for your group members
for the first meeting?
CASE STUDY 13.1 GOOD PRACTICE IN GROUP WORK

The Family Links Nurturing Programme is a support ■ developing communication and social skills
programme which works with parents and has been ■ teaching positive ways to resolve conflict
developed in all the schools in South Southall, ■ providing effective strategies to encourage
London. It complements the existing parental support cooperative, responsible behaviour and managing
provided by schools and helps to build capacity for challenging behaviour in children
further outreach work with families. The programme ■ offering insights into the influence of feelings on
consists of 10 weekly group work support sessions at behaviour
the schools which focus on parents sharing ■ encouraging adults to take time to look after
techniques with one another in order to build better themselves.
relationships with their children and improve their The nurturing group supports positive behaviour in
confidence in parenting. The group work programme children and explores the emotional needs behind
is based around four main ideas: building self their behaviour. Overall, the programme is founded in
awareness and self esteem, developing appropriate the knowledge that empathic relationships in
expectations, empathy and positive discipline. The childhood have an important effect on the developing
support groups are designed to promote emotional brain, on the way we learn to manage emotions and
health in adults and children, enable families to sensitively relate to others. These are both key factors
improve their relationships and empower parents to in the way we behave and an important contributor
fulfill their potential in all aspects of their lives. to lifelong health and wellbeing.
The programme benefits both adults and children by:
■ promoting emotional literacy and emotional health
■ raising self-esteem.
(Case study produced by Natalie Shepping, South Southall Extended Schools Coordinator, London.)
leaders and members and the way in which groups ■ If you facilitate groups, you will find it helpful to
develop over time. develop a range of skills and strategies for getting
■ Thorough planning and preparation are essential for groups going, encouraging discussion, and dealing
successful group work, which includes having a with difficulties.
clear rationale and aims, and paying attention to
recruitment, venue, facilities, resources, timing and
evaluation.
References
Belbin RM 1981 Management teams: leader’s handbook. Chichester, Stock Whitaker D 2001 Using groups
why they succeed or fail. Oxford, Wiley Blackwell. to help people, 2nd edn. Hove,
Butterworth-Heinemann. Doel M 2006 Using groupwork. Brunner-Routledge.
Bertram L 2008 Supporting postnatal Oxford, Routledge. Tuckman BW 1965 Developmental
women into motherhood: a guide Hogg MA, Scott Tindale R (eds) sequence in small groups.
to therapeutic groupwork for health 2002 Blackwell handbook of Psychological Bulletin 63: 384–399.
professionals. Oxford, Radcliffe. social psychology: group
Buckroyd J, Rother S 2007 Therapeutic process. Oxford, Blackwell:
groups for obese women: a group Chapter 26.
191
Chapter 14
Enabling healthier living
Summary
Chapter Contents
This chapter considers the approaches used to support
Models of behaviour change 192 people in making changes to their health-related
behaviour. In the first section there is an overview of
Working with a client’s motivation 195
two behaviour change models. This is followed by a
Working for client self-empowerment 195 section on working with a client’s motivation and how
to work towards client self-empowerment, strategies
Strategies for increasing self-awareness, clarifying
for increasing self-awareness, clarifying values and
values and changing attitudes 196
changing attitudes. Strategies for decision making
Strategies for decision making 198 and for changing behaviour follow. The chapter ends
with principles for using behaviour change approaches
Strategies for changing behaviour 199
effectively and summarises key points. It includes
Using strategies effectively 201 exercises, examples and a case study.
This chapter focuses on the competencies you need

when you are enabling people to make changes to
their health-related behaviour and lifestyles. Health
behaviour may have developed without conscious
decision making and in response to individual and
group circumstances and external events. Active
control of behaviour is different because it involves
committing time and effort (yours and your cli-
ent’s) to understanding the factors that influence
health choices and behaviour, and to taking consid-
ered decisions and actions.
However, it has to be accepted that people may
prefer to carry on with behaviour that seems
unhealthy to you. To a client, it may not seem
unhealthy as the benefits outweigh the risks.
Respect for people’s values, opinions and their
right to choose are fundamental to establishing rela-
tionships between health promoters and their
clients.
See Chapter 10, section on exploring relationships with

BOX 14.1 Counselling about a health choice
clients.
A health visitor has the task of helping parents to
On the other hand, you also have to consider that
decide what to do about having their baby vaccinated.
a person’s right to individual freedom of choice has
The stages could be:
to be balanced against the effect of that choice on
other people; for example, a parent choosing to Stages 1 and 2. Identify and explore the need
smoke could affect their children’s health by sub-
For example, are the parents worried about having the
jecting them to passive, secondary smoking.
child vaccinated at all, or is it just the whooping cough
Furthermore, choosing a healthy behaviour does
vaccination which is worrying? Is it when to have the
not automatically lead to practising it. Changes
child vaccinated, or if?
such as taking more exercise, practising relaxation,
wearing ear protectors in noisy surroundings, Stage 3. Help the client to set goals and establish
eating healthier foods and stopping smoking can options
require self-discipline and overcoming barriers
For example, the parents may identify the goal of the
which make these changes stressful. Social or eco-
child having the best possible chance of staying healthy.
nomic circumstances can be a significant obstacle to
The options might be: no vaccinations at all, some
people carrying out new health behaviours, even if
vaccinations or all the vaccinations.
they would like to (Parliamentary Office of Science
and Technology 2007). Stage 4. Help the client to decide which option
However, despite these limitations, it can be very to choose
rewarding to enable people to look at their motiva- ■ Weigh up the pros and cons. The health visitor
tions, beliefs, values and attitudes, and to make and provides unbiased information on the risks from
carry out decisions that will lead to improved health catching each disease compared with the risks of
and wellbeing (Box 14.1). having the vaccinations.
■ Consider the likely consequences of pursuing each
Models of Behaviour Change alternative: for the child in terms of health risk,
for the parents, in terms of anxiety, guilt and
Health-related behaviour change is a very complex responsibility, for other people in terms of
process involving a web of psychological, social spreading the diseases.
and environmental factors. Using behaviour change Stage 5. Help the client to develop an action plan
models will help you to clarify your thinking and
make your practice more effective. Models are sim- For example, the parents may decide to go ahead with
plified ways of describing reality and provide the vaccination programme, but also to join a parents
frameworks and routes to help you know where to group, in order to get support from other parents facing
start and what to do. Two models that can be used the same anxieties and decisions. The health visitor
by health promoters are the Health Action Model suggests to the parents that they keep a record of the
and the Stages of Change Model. vaccinations for future reference, and provides them
with a record card for their child. They set a date for
the first vaccination.
The Health Action Model
The Health Action Model (HAM) was devised by
Tones (1987, and Tones & Tilford 2001) and empha- concentrating on boosting people’s self-esteem and
sises the important influence of self-esteem on their skills in resisting peer group pressure. Accord-
behaviour. It assumes that someone with high self- ing to this model, learning life skills such as how to
esteem and a positive self-concept is likely to be be assertive may be essential before someone is
more motivated towards ways of healthier living ready to change their lifestyle.
and that people with low self-esteem may feel that The HAM identifies a variety of psychological,
they have limited control over their behaviour and social and environmental influences which research
that they are victims of bad luck or fate. Many and practice have shown to be important determi-
health promoters, particularly those working in the nants of a number of health choices. The model
field of drugs, have used this model, through offers an explanation about how these influences
Chapter 14 Enabling healthier living 193
Health action Routine

Facilitating factors
Re-appraisal and
Knowledge and skills possible relapse
Supportive environment
Decision
Behavioural intention
Self concept Self-esteem
Belief system Motivation system
Normative system
Health promotion input
Fig. 14.1 The Health Action Model. (Source: Tones 1995. Reproduced with permission from the Health Education Authority).
work. It suggests that health decisions and actions consider all the stages in the process, and how
are influenced by our beliefs, our values, our moti- people move from one stage to another. The Trans
vation, our expectations of how other people will theoretical Model (TTM) developed by Prochaska
react to our actions and our self-concept and self- & DiClemente (1982) is rooted in extensive research
esteem (see Fig. 14.1). and integrates a range of psychological theories.
The HAM is concerned with empowerment, The TTM has evolved over time and now contains
with increasing the control people have over their five core constructs: stages of change, processes of
lives. It suggests that health promotion should not change, decisional balance, self-efficacy and temp-
just focus on the provision of information and the tation (Prochaska & Velicer 1997) which provides a
pros and cons of particular behaviours. More valuable conceptual framework for how people
important than this are interventions that enable naturally change their behaviour. However, there is
people to value themselves, and to acquire the skills controversy and debate about whether this can con-
to assert themselves. Equally important is the pro- sistently be translated into an intervention pro-
vision of environmental circumstances that facili- gramme (see, for example, Aveyard et al 2009 and
tate healthy choices, rather than acting as barriers. Prochaska 2009). Studies based on this model, such
And at a broader level, national and local policy as Aveyard et al (2006) found no evidence that the
needs to address the broader determinants of smoking cessation intervention based on the model
health, such as poverty and deprivation. was more effective than a control intervention that
was not tailored for stages of change. Armatage
(2009) offers a useful critique of the model and an
Transtheoretical Model (TTM)
assessment of three studies that deemed to have
and Stages of Change
successfully utilised the processes of change to
One way of supporting people in making health- reduce alcohol consumption, encourage smoking
related decisions and changing their behaviour is to cessation and increase physical activity. It is
important before using the approach to be abreast in the process of changing health behaviour, such
of the controversy and the systematic reviews on as stopping smoking, taking more exercise regu-
it’s effectiveness. A useful summary with a full set larly or adopting healthier eating. A crucial point
of up-to-date references is presented on Wikepedia is that the cycle can be thought of as a revolving
(http://en.wikipedia.org). door, because people usually go round more than
The stages of change component of the TTM once before emerging to a permanently changed
identifies a number of stages that a person can go state. It is also important to recognise that some
through during the process of behaviour change. It people may never get as far as entering the revolv-
takes a holistic approach, integrating factors such ing door.
as the role of personal responsibility and choices, Pre-contemplation stage. The stage that precedes
and the impact of social and environmental forces entry into the change cycle is referred to as pre-
that set very real limits on the individual potential contemplation. At this stage a person has no aware-
for change. It provides a framework for a wide ness of a need for change, or does not accept it, and
range of potential interventions by health promot- has no motivation to change habits or lifestyle.
ers, as well as describing the process individuals go Contemplation stage. This stage is the way into the
through when acting as their own agents of change; revolving door cycle of stages of change. People
for example, when someone stops smoking without enter this stage when they have enough motivation
any professional support. The main stages identi- to contemplate seriously changing their habits; the
fied in the model are set out in Fig. 14.2 (see also entry stage is therefore called contemplation.
Prochaska 2005). Commitment stage. If people continue to progress
The key to the model is to regard the cycle in the round the cycle, they enter the commitment stage,
centre as a series of stages that people go through in which they make a serious decision to change the
particular habit concerned, such as stopping
smoking or taking more exercise.
Exit:
Maintaining ‘safer’
Action stage. They next enter the action stage as
lifestyle they actively begin to change the habit.
Maintenance stage. At this stage people struggle
to maintain the change and may experiment with a
variety of coping strategies.
Action: Relapse stage. Although individuals experience
Making the satisfaction of a changed lifestyle for varying
changes
Maintenance: amounts of time, most of them cannot exit from the
Maintaining revolving door the first time around. Typically, they
change relapse; for example, they start smoking again. Of
Commitment:
Ready to great importance, however, is that they do not stop
change there, but move back into the contemplation stage,
Relapse:
engaging in the cycle all over again. Prochaska et al
Relapsing (1992) found that, on average, successful former
Contemplation: smokers take three revolutions of change before
back
Thinking
they find the way to become fully free of the habit,
about
change and exit from the revolving door.
Exit stage. This is the stage in which people are
settled into a changed behaviour, such as stopping
smoking permanently.
By identifying where clients are in the stages of
change, health promoters can tailor their interven-
Pre-contemplation: tions to the particular stage. For example, behav-
Not interested in
changing ‘risky’
iour change strategies are appropriate for someone
lifestyle in the action or maintenance stages; education and
awareness raising are appropriate for someone in
Fig. 14.2 Stages of changing health behaviour. (Adapted the pre-contemplation stage; working for client self-
from Prochaska & DiClemente (1984) and Neesham (1993)). empowerment is appropriate for someone in the
contemplation stage; strategies to help people to person has about themselves. Self-efficacy can
make decisions are useful for those in the commit- vary in different situations, and you can help your
ment stage. clients look at different approaches for improving
The model can be useful in primary healthcare self-efficacy in situations where they feel less
settings, because clients’ needs can be assessed and confident.
appropriate advice or information given, within the This section is partly based on Rollnick et al
constraints of a short consultation. (1999). See also Botelho (2004) and Rollnick et al
(2007) for more on motivational practice.
Working with a Client’s

Dangerous Assumptions
Motivation
about Motivation
Motivation is a state that changes frequently Health promoters can become very focused on
depending on lots of different factors. If people are health issues, and may forget that there are other
struggling to maintain their new behaviour, what motives for change and that health might not be one
gets them through this difficult time without relaps- of them. The list below illustrates some of the other
ing? It is thought that both the importance of the new assumptions that are easy to make when counsel-
behaviour (in terms of the expectation of costs and ling clients.
benefits) and the confidence of the person being able ● This person ought to change.
to maintain the new behaviour are essential to ● This person wants to change.
prevent relapse. The following suggestions can help
● It is the right time for this person to change.
you explore the importance of the new behaviour
● If this person decides not to change, this
with clients, and to build their confidence.
intervention has failed.
● A tough approach is always best.
Ideas for exploring importance
● For this person, health is a prime motivator.
● What are the positive aspects of the current ● I’m the expert. This person must follow my
behaviour? advice.
● What are the negative aspects of the current
behaviour?
● Summarise and ask ‘And is there anything Working for Client
else?’ Self-Empowerment
● Where does that leave you now?
Making health choices and carrying them out can
bring benefits. These are not only the benefits that
Ideas for building confidence go with a healthier lifestyle, such as improved
● Get the client to identify as many solutions as
health and wellbeing, but also increased self-esteem
possible which will help to prevent relapse. from the feeling of taking active control over a part
of life, such as being in control of the smoking habit
● Ask ‘What have you learned from previous
rather than cigarettes being in control. In other
attempts to change about what works (or
words, making a positive choice about health can
doesn’t work) for you?’
be a self-empowering process.
● Ask ‘Are there methods that you know have
There are a number of different ways of working
worked for other people?’ towards self-empowerment. Using the Stages of
● Aim to help the client develop a clear plan but Change is empowering, because people can follow
explain that it can be reviewed at any time. their own progress. It may encourage them to try to
It is essential to listen actively to the client when get to the next stage of the cycle, and not to see
exploring readiness to change. Confidence can be change as all-or-nothing. Also, the recognition that
divided into self-efficacy and self-esteem. Self-efficacy relapse can be part of the process of changing
is concerned with a person’s confidence in being behaviour is important (see Marlatt & Donovan
able to make a specific change in behaviour; self- 2007). Behaviour change messages can be tailored
esteem is a more general sense of wellbeing that a to individual need, for example through providing
clients with access to specially designed computer a person considering making improvements to his
programs (Walters et al 2006). Other methods diet might be ready to make one change (such as
include group work and experiential learning, indi- eating more fruit and vegetables) but not ready to
vidual counselling and therapy, and advocacy, all make others, such as changing to lower fat milk;
of which are considered in the following sections, an overweight person may be ready to take more
except therapy, which is beyond the scope of this exercise but not to change his eating habits. By
book. Unless you are a mental health specialist, writing down all the areas or issues that could be
most people you work with probably do not need changed and asking ‘Are there any of these you
in-depth therapy. think you could discuss changing?’, you can get
The process of empowerment involves helping agreement to discuss one particular topic (Rollnick
clients to become more self-aware, and have greater et al 1999).
insight into, and understanding of, themselves,
their attitudes, values, motivations and feelings
Ranking or Categorising
Ranking is a way of analysing an issue in order to
Strategies for Increasing distinguish the relative importance of different
Self-Awareness, Clarifying aspects. It is therefore useful for clarifying values.
Values and Changing Attitudes For example, in Exercise 1.1 in Chapter 1, readers
are asked to rank aspects of being healthy. Health
Many of the strategies that are useful for increasing is a value and that exercise is designed to help
self-awareness, clarifying values, developing belief readers to clarify which aspects of health they value
systems and changing attitudes for the contempla- most.
tion stage of change are designed for group work. See Chapter 1, section on what does being healthy mean
However, some of them can be adapted for health to you?
promoters to use in one-to-one situations.
Another approach to increasing self-awareness
See Chapter 13, Working with groups. and values clarification is to generate a list of items,
All these strategies use the principle of experien- and then code them into different categories. Exer-
tial learning, which emphasises the importance of cise 14.1 illustrates this approach; it is designed to
personal experience as a source of learning. Experi- raise awareness of the link between enjoyment and
ential learning has evolved from two sources. One health.
is from the theories of the American philosopher
Dewey (1938). Another is from humanistic psychol- Using Polarised Views
ogy. Humanistic psychology sees people as free
decision makers actively controlling their own des- This is a way of getting people to clarify their views
tinies. Humanistic psychology has had a huge influ- about a particular issue. Views about the issue are
ence on healthcare, education and health promotion polarized and phrased to reflect extremely different
both in the UK and worldwide. The literature is views. For example, if the issue was ‘Is jogging
vast. One classic text is Rogers (1967). Experiential good for you?’, polarised views could be summed
learning is active learning undertaken through up as ‘Jogging kills people and only very fit athletes
exercises and other activities designed, for example, should do it’ or ‘Jogging is very beneficial to health
to increase self-awareness or aid decision making. and all people would be fitter if they took it up’.
Examples of polarised views can be described by
See Chapter 12 on helping people to learn. the group leader or taken from writings that express
opposite views.
The group leader may ask people to work in
Deciding What to Change
pairs, with each individual acting as if he fully
Some clients could benefit from making several life- adopted one of the points of view for the duration
style changes to improve their health, and it can be of the exercise, whatever his personal opinions.
tempting to try to address all of them at the same First, each person writes down all the arguments he
time. But people are often at different stages of can think of that support his position, without dis-
readiness to change on different issues. For example, cussing it with his partner at this stage. After a few
on the blackboard. The group members are then

EXERCISE 14.1 Enjoyment and health
asked to mark or place themselves at a point along
Quickly list as many things as you can think of that you the line that best reflects their own view. For
enjoy doing. Write them down the left-hand side of a instance, in the jogging example discussed above,
piece of paper. On the right-hand side, code each item pro-joggers place themselves at one end, with the
according to the following categories. most extreme at the farthest point, people with
£ – any items that involve spending money. moderate views stand around the middle, and the
A – any items that you do alone. most ardent anti-joggers stand at the other end. The
P – any items you do with other people. leader asks each person to state his views briefly as
R – any items that involve some kind of risk. he takes up his position. Other people are asked not
F – any items that help to keep you fit. to interrupt or comment until everyone has taken
C – any items that involve creativity. up a position, or has passed if they choose not to
D – any items that involve consumption of drugs participate.
(including alcohol and tobacco). This technique can encourage a more detailed
H+ – any items that positively affect your health. discussion of the range of possible options than the
H− – any items that negatively affect your health. polarised argument technique. On the other hand,
Items may be coded in more than one category. For if everyone seems moderate, a better discussion
example, if one of the things you enjoy is going out to may be stimulated by the polarised argument
the pub for a drink, this may be coded £, P and D, as technique.
well as H+ and/or H−.
The values continuum technique is used in the last task
What have you learned about enjoyment and health
of Exercise 3.1 in Chapter 3.
through doing this exercise?
Using Role-Play
Role play generally means taking on the role of
minutes, the partners are asked to start arguing the another person in a specified situation, and acting
case, usually for about 15 minutes. The leader then out what that other person might do and say in that
lists the points in favour of each view by asking situation. This helps people to understand what it
each pair in turn to contribute one point, until all feels like to be in another person’s shoes. For
the points have been collected. She then asks the example, health promoters role-playing non-
group to comment on what they have learnt. In this English-speaking patients visiting a clinic may be
way, members of the group can consider a whole helped to understand how those patients feel, espe-
range of arguments, which helps them to under- cially if the role-play is given added authenticity by
stand other people’s points of view, tolerate differ- using a foreign language that the health promoters
ences of opinion, clarify their own views and do not speak.
perhaps see the issue in a new light. It is also possible to role-play oneself in a new
situation. This is a useful way of practising a new
Another example of a values clarification exercise using
skill or rehearsing for a future event. For example,
the polarised arguments approach is Exercise 3.1 in
patients can role-play a consultation with a doctor
Chapter 3.
in order to practise the skills of presenting their
health problems to doctors.
Using a Values Continuum
For an example of a role-play exercise, see Exercise 12.2
This is an extension of the polarised argument tech- in Chapter 12.
nique. It helps people to understand the spread of
opinion on a particular issue and to clarify where
they stand.
Using Structured Activities
The leader describes two extremes of opinion Structured activities, usually for a group of people
and asks the group to imagine that these can be but sometimes for one or two people only, can be
represented by two points, A and B, joined by a used to meet a variety of aims. One is to help people
straight line. With a small group this line can be to get to know each other – icebreakers; other activi-
across a room; with a large group it could be drawn ties are devised to help people trust each other,
communicate more openly or to increase

Strategies for Decision Making
self-awareness.
See Chapter 13, section on getting groups going, for As a health promoter, you may be involved in coun-
icebreaker ideas. selling with the aim of enabling people to make a
choice, such as which treatment to have, whether to
For example, activities can be used to help people
have a blood test for HIV, or how to select healthy
to identify irrational beliefs. Irrational beliefs are
foods in particular circumstances.
misconceptions that hinder people from achieving
their goals. For a detailed overview of irrational See Chapter 10 on Fundamentals of communication.
beliefs see David et al (2009). There are three major Basic skills of counselling to help people make
irrational beliefs: decisions at the commitment stage of change are
1. I must win everybody’s approval otherwise I those discussed in Chapter 10: understanding non-
am worthless. verbal communication, listening, helping people to
2. Other people must treat me exactly how I want talk, asking questions and obtaining feedback. For
them to, and if they don’t they must be blamed those of you who require a level of counselling skill
and punished. but are not trained counsellors or therapists, see
3. Life must give me everything I want and Mcleod (2007) for an introduction to counselling
nothing I don’t want. techniques across all disciplines.
There are at least five stages involved (adapted
These beliefs lead to self-defeating thinking, which
from Burnard 1985 and Inskipp 1993). These stages
in turn can affect health. It can lead to health-related
may seem familiar to you because counselling
behaviour with destructive consequences, such as
involves a framework of planning and evaluating
emotional disorders, heavy drinking and physical
similar to the one we used in Chapter 5.
ailments. The quiz in Exercise 14.2 aims to help you
identify your own irrational beliefs. See Chapter 5, Planning and evaluating health promotion.
EXERCISE 14.2 Beliefs quiz

Look at the following statements and put a tick in the Q2. If you agreed with this statement you may believe
appropriate column: that human happiness can be achieved by hoping for the
Agree Disagree best and waiting to see what happens. This belief could
1. I believe in the saying, ‘A leopard   result in you becoming merely a spectator in life,
cannot change his spots’. watching television every night and somnolent on a
2. I believe that ‘wait and see’ is a   sun-lounger for the whole of your holidays. Getting more
good philosophy for life. actively involved could be more satisfying and actually
3. I want everyone to like me.   provide you with more energy. If you feel too exhausted,
4. I usually put off important   now may be the time to take a close look at how you are
decisions. managing your life and make some changes.
Q3. If you agree with this statement you may believe
Now identify your rational beliefs and your irrational
you are only as good as other people think you are.
beliefs (misconceptions):
Because of this you may feel worthless if, despite your
Q1. If you agreed with this statement you may believe
efforts, people don’t seem to like you. Having the approval
that the past has a lot to do with determining the present
of others is pleasant, but in order to run our own lives we
and that people are largely unchangeable. ‘I’m made that
shall almost certainly have to do some things some people
way.’ The idea that you are no good at playing sports, for
do not like. Work on giving yourself the approval you
example, can be used to avoid trying out new behaviour
deserve.
and learning the skills necessary to participate in a sport.
Q4. If you agreed with this statement you may believe
The truth is that people who take risks, experiment and
that life’s problems will go away if you avoid them. Don’t
work on things generally find that they can become
waste your time hoping that things will work out; make
reasonably competent at most of the things they attempt;
them.
not necessarily perfect, but good enough.
Stage 1: Identify the need and create Stage 4: Help the client to decide which
the climate option to choose
Rogers (1983), an early pioneer of counselling, iden- The important thing about this stage is that the
tified the qualities necessary for a counsellor to choice must be the client’s, not the counsellor’s.
establish a climate in which a client can open up. Making decisions – that is, choosing between alter-
These are warmth, openness, genuineness, empathy native options – is a highly complex process. It
and unconditional positive regard. Unconditional involves:
positive regard is the quality of totally respecting ● Weighing up the pros and cons of the
the worth and dignity of a person, irrespective of alternative options.
whether you like the person or agree with his views ● Considering the likely consequences of
or behaviour. pursuing each alternative.
The practical aspects of creating the climate
● Deciding which is the best alternative.
include ensuring that you will not be interrupted
● Having the confidence to pursue the best
and cannot be overheard, that you have sufficient
time and that you are comfortably seated in chairs alternative.
of the same height, with the counsellor adopting an If the client is reluctant to commit to a decision, then
open posture and making direct eye contact when both parties need to consider whether it is worth
appropriate. undertaking further work at stages 2 and 3.
If the client chooses an alternative that the coun-
sellor feels may not work, they should nevertheless
Stage 2: Explore the needs and back the client’s choice and help them to develop
the concerns an action plan, knowing that if it doesn’t work,
there is still the possibility for exploring other
Through giving full attention and actively listening, options.
by encouraging the client to talk and by asking
questions, the counsellor begins to establish trust
and to enable the client to move from superficial Stage 5: Help the client to develop
issues to deeper needs and concerns. an action plan
Having made a decision, the client now needs to
Stage 3: Help the client to set goals think about turning that decision into action. They
and identify options may need to identify coping strategies and sources
of support. Once an action plan has been agreed,
Having gained a new perspective on the issues and the final details are to set a review date and to
concerns, it becomes possible for the client to iden- clarify how progress will be monitored.
tify goals and ways these might be achieved. The
counsellor could help the client to identify themes See next section on strategies for changing behaviour.
or to get a clearer vision of the future by asking key
questions, such as:
‘How would you feel if …?’ Strategies for Changing
‘If things were exactly how you wanted them Behaviour
to be, how would they be different from now
…?’ Having made a choice, people may need consider-
‘Have you ever felt like that on other occasions able help to carry their decision through into the
…?’ action stage of change. A number of techniques
developed from behavioural psychology are useful,
The counsellor may also provide the client with
and the philosophy behind them, that people are
information in order to establish options:
responsible for their own behaviour and are capable
‘If you do X, what’s likely to happen is …’ of exercising control over it, is as important as the
‘If you do Y, the chances are that …’ techniques themselves. For further reading on strat-
‘You might find it helpful to consider that …’ egies for changing behaviour see Jenkins (2003) and
and so on. Browing (2005).
A variety of material has been developed to help Identifying Costs, Benefits

people to change different aspects of their behav- and Rewards
iour. For example, the Department of Health Change
for Life campaign (http://www.dh.gov.uk) has a The cost of changing behaviour can be considera-
range of interactive tools and information that ble, involving deprivation of what might have
clients would find useful in supporting their change become support mechanisms, such as cigarettes,
efforts. and pleasures, such as eating and drinking, or there
Some useful techniques are as follows. may be a heavy price to pay in terms of time, effort
and perhaps money. So it is helpful to identify the
benefits clearly, and set up a system of rewards to
Self-monitoring encourage perseverance.
Self-monitoring involves keeping a detailed and Benefits may be long term, such as better health
precise account, often in the form of a diary, of or increased life expectancy. They may be abstract:
behaviour that is to be changed. Its aim is to help ‘It will prove I’ve got will-power’, or in other peo-
people to analyse their pattern of behaviour and ple’s interests: ‘For the family’s sake’. These benefits
become fully aware of what they are doing, which may be important but it is also necessary to find
is a starting point for gaining control. Second, the immediate, short-term rewards that people genu-
diary provides a baseline against which progress inely enjoy, such as small treats.
can be checked.
Self-monitoring involves answering questions Setting Targets and Evaluating
such as: Progress
● How frequently does the problem occur?
Targets should be realistic rather than idealistic.
● When the problem occurs, what else is
Losing up to a kilo in weight a week is realistic for
happening, both externally (in the environment),
most people; losing 7 kilos in a month usually is
and internally (in thoughts and feelings)?
not. People may have unrealistic hopes and expec-
● What event leads up to the problem?
tations about what can be achieved, which lead to
● What happens afterwards: the consequences? disappointment and a sense of failure when they
Box 14.2 is an example of a smoker’s diary. don’t meet the target.
BOX 14.2 A smoker’s diary

Day…………………… (Complete one of these charts every day.)
Each time you smoke a cigarette, note down in the columns:
1. The time.
2. How urgent your craving for a cigarette is, on a scale of 1–10 (1, very little craving; 10, extremely high
craving).
3. Where you smoke the cigarette.
4. Whether you are alone or who you are with.
5. Do you smoke it with drinks (coffee, tea, alcohol)?
6. Do you smoke it after a meal?
7. What else are you doing at the time (for example, chatting, reading the paper, working, talking on the phone)?
8. Why did you decide to smoke this cigarette?
9. What do you feel about it afterwards?
Time Craving Where Who With After Doing Why Afterwards

with drinks meal what
In order to evaluate progress, it is necessary to keeping alcohol in the home or restricting

keep a record of behaviour so that achievements eating to meal times, not between meals.
can be seen clearly. Progress should be assessed What all these strategies have in common is that
once the new behaviour has been given a fair trial, they require only a small step to achieve a large
perhaps for 2 or 3 weeks, although short-term degree of help for self-control. Other strategies may
reviews (‘How have I done today?’) can also be be:
useful.
● Getting support from other people in the same
If the target is not being achieved, possible
situation, who might be from a weight control
reasons must be looked for and changes made. For
group, a smoking cessation clinic or a self-help
example:
group. Another helpful way of getting support
● Is the target too difficult? Should it be lowered? is by linking with another person on the
● Are the rewards too distant? Is there a more understanding that each may telephone or meet
immediate reward that could be more the other if they need help.
encouraging? ● Practising ways of responding to unhelpful
● Is there an unforeseen crisis or illness? If so, social pressures, for example refusing the offer
encouragement to continue self-monitoring and of a cigarette or a drink.
to look on the setback as a learning experience ● Adopting a 1-day-at-a-time approach. The
may be needed. prospect of the whole of the rest of life without
● Are other people unhelpful? More strategies to a cigarette may be overwhelming, but the
cope with the negative influence of other prospect of 1 day without one is far more
people may be needed. tolerable. Even shorter time spans may be
● Are there other problems which require support, helpful, such as putting off eating, drinking or
such as learning to cope with anxiety or stress, smoking for just 15 minutes at a time.
lack of the resources required to fund changes? ● Learning relaxation techniques and other ways,
such as exercise, of relieving stress. Simple
relaxation routines that can be practised at any
Devising Coping Strategies time and place can be helpful in coping with
stressful moments when the habit would have
Changing behaviour can mean coping with numer- been to reach for a drink or a cigarette.
ous difficulties, for at least a short period of time,
until the new behaviour becomes a normal part of
life. Someone who is stopping smoking has to cope
Using Strategies Effectively
with problems such as the craving they feel, the
need to put something in their mouth, not knowing
A number of different strategies have been covered
what to do with their hands, doing without their
that you can use when you are trying to help clients
accustomed tension reliever in moments of stress
to increase their self-awareness, clarify their values
and resisting the offer of a cigarette.
and beliefs, change their attitudes and behaviour
People adopt a wide variety of coping strategies,
and maintain behaviour change; in other words to
and it is often useful to get a group to share their
move them through the Stages of Change cycle.
ideas about what helps them to cope. The list of
While it may be relatively easy to influence atti-
strategies here is certainly not exhaustive.
tudes and behaviour in the short term, it can be
● Finding a substitute, such as substituting difficult for people to sustain behaviour change
chewing gum for cigarettes or eating low- over a longer period. In order to use these strategies
calorie instead of high-calorie foods. with maximum effect there are a number of princi-
● Changing some routines and habits that are ples to bear in mind.
closely associated with the unhealthy
behaviour. Examples are drinking tea or fruit
juice instead of coffee, because coffee is closely Advocacy and Working
associated with cigarettes. in Partnership
● Making it difficult to carry on with the Some people may need extra help to make health
unhealthy behaviour by, for example, not choices. Advocacy is generally taken to mean
representing the interests of people who cannot exercise by cycling to work; provision of litter bins,
speak up for themselves because of illness, disabil- combined with frequent emptying, helps people to
ity or other disadvantage. In the context of health maintain a litter-free environment. National and
promotion, it is better seen as a variety of ways of local policies can create a climate where it is easier
empowering those people who are disempowered to adopt healthier behaviour.
in our society. It is concerned with using every pos-
See Chapter 1, section on what affects health and
sible means to assist people to become independent
Chapter 16, section on changing policy and practice.
and self-advocating.
There can be deep conflicts of loyalty for health Undertake Exercise 14.3 to apply some of these
promoters who take on an advocacy role. There ideas to an example of a behaviour change
may be a need to challenge employers, or those in scenario.
authority, about services that fail to meet people’s
needs.
Relating to Clients
For example, if a patient complains to a commu-
nity mental health nurse that his drugs are making
See Chapter 10, section on exploring relationships with
him feel drowsy and generally unwell, but the
clients.
doctor insists they should continue to take them,
where should the nurse’s loyalties lie: to the patient, Clients are more likely to change if the health
to the doctor, to the health service (their employer) promoter understands the client, sees things from
or to their professional body? How can the nurse their point of view and accepts them on their own
most effectively act as an advocate in this terms. Achieving this relationship may be the most
situation? difficult part of helping people to change.
Because of such conflicts of loyalties, many advo- Sometimes it is difficult to start a discussion
cacy schemes use nonprofessional workers who about changing behaviour, and establishing good
come from a similar background to those they are rapport is essential for an honest discussion and
empowering. For example, Maternity-Links openness for change. One way you can understand
schemes provide workers as advocates and inter- your client and also assess readiness to change is to
preters for Asian mothers who do not speak English ask the client to take you through a typical day with
(http://www.bfwh.nhs.uk). The workers are Asian reference to a particular behaviour.
themselves but able to speak English as well as their It is important to note that the attitude and
own mother tongue, and the organisation may be behaviour of the health promoter may influence the
run with health service funding but managed outcome. For example, an obese health promoter
independently. may find it more difficult to encourage an obese
In order to reach and influence disadvantaged client to adjust their dietary habits. The experiences
groups of people successfully, many projects involve of health promoters in trying to change their own
professionals working in partnership with lay vol- behaviour, however, can be valuable in helping
unteers. For example, a community mothers’ pro- them to understand the difficulties that their clients
gramme involved nonprofessional mothers as experience. However, it is important to remember
volunteers working with disadvantaged first time that everyone is different and that, although for
mothers to improve their parenting skills (Settles some people making a particular change may be
et al 2000). easy, for others a similar change may prove very
difficult.
Making Healthier Choices
Easy Choices Dealing with Resistance
People make health choices in the context of their It is sometimes difficult for health promoters to stop
own environment, subject to all the pressures and providing advice when they know that a particular
influences that surround them. If this environment behaviour, such as stopping smoking, can have
is conducive to a healthier lifestyle, clients have huge benefits for the client. It is important to recog-
greater freedom to choose the healthier alternatives nise when your clients are showing signs of resist-
and change their behaviour. For example, the provi- ing the suggestion to change. When you see this
sion of cycleways makes it easier to take regular resistance, it is better to express empathy, emphasis-
EXERCISE 14.3 Changing behaviour in practice

Read the following example of behaviour change much sleep. Gemma says she wants to do something to
approach and answer the questions that follow: help her child sleep. Mary explores how confident Gemma
Gemma is a single parent. She has a toddler who feels in being able to make some changes. Mary also asks
constantly wakes her at night. She has used various Gemma if she knows of anything that seems to help her
strategies, including trying to tire him out physically just child to relax, and using her suggestions they devise a
before bed time, keeping him up later, leaving toys for suitable bed-time routine for Gemma to try out. Mary
him to play with in the night and playing with him herself recognises that Gemma is concerned about her drinking
in the night. She has started to buy vodka cocktails and and asks her for suggestions of what she could do about
cans of lager in the supermarket to drink in the evenings it. Gemma says she feels that her drinking is related to
to help her relax and now finds that she needs another her stressful situation and that once her child sleeps
drink to help her get back to sleep after getting up in better she will feel more in control.
the night. Finally, Mary suggests that she should come back to
She phones her health visitor – Mary – for help. Mary see Gemma in 2 weeks’ time to discuss whether the new
goes to see her and asks her to describe a typical day routines are helping her child to sleep. Gemma agrees.
(and night) in order to understand the situation better. Mary makes a note to ask Gemma about her drinking on
She asks Gemma to describe the situations she struggled the next visit.
with, how she felt at the time and what she did. As ■ What strategies does Mary, the health visitor, use
Gemma’s story unfolds Mary gains knowledge of Gemma’s to help Gemma?
variation in mood states, existing coping strategies and ■ What other strategies could Mary have used?
support base. ■ What strategies might Mary want to use at the
Mary gets Gemma to reflect on her daily achievements follow-up visit?
and emphasises that it must be a struggle for her without
ing that it is the client’s personal choice and that ● Emphasise that participation is entirely
they have control over their lifestyle choices. Useful voluntary.
strategies for these clients at a later date are to reas- ● Allow plenty of time for discussion at the end.
sess readiness to change, establish how important If people’s opinions and cherished ideas have
the behaviour change is to them and how confident been challenged, they are likely to feel strongly
they feel about making the change. about it. Increased self-awareness may be a
very uncomfortable experience too. The group
leader should ensure that people have time to
Using Methods Sensitively
express their feelings and get any support that
People invest a great deal of emotion in their values they need before they leave the group.
and attitudes, which means that the exercises ● Ensure that there is an atmosphere of
described here, especially those that are designed to confidentiality and trust, so that people feel free
encourage people to explore feelings, need to be to explore their views and feelings in safety.
handled with care and sensitivity. Special training ● Save your own views to the end, after the
in the use of experiential methods is recommended group members have had a chance to think
but, at the very least, health promoters should not things through for themselves. Be open and
attempt to use them unless they have experienced honest about yourself and your beliefs, and
them first themselves. Some points to remember are nonjudgemental of values that might conflict
as follows: with your own.
● Explain the activities carefully and thoroughly,
and check to ensure that everybody Finally, for detailed guides to changing health
understands what the exercise is for and what behaviour see Rutter & Quinne (2002) and Kerr et al
they are expected to do. (2005).
PRACTICE POINTS go back to explore again the individual’s confidence

about changing and how important the change is to
■ For individuals to be ready to change a particular them.
behaviour they need to feel confident in being able ■ You need to tailor an action plan to the specific
to adopt the new behaviour. The new behaviour also needs of each client and provide positive
needs to be important to them and have clear consequences for the desired healthy behaviour
benefits. You may need to help clients develop a (such as praise or rewards) in order to maintain
number of competencies or life skills to do with behaviour change.
social interaction, assertiveness and time
■ You can improve success by combining a number of
management, and possibly specific skills (such as
strategies. For example, a patient who is being
those needed to participate in a physical exercise
rehabilitated after a heart attack could have an
programme).
interview with a hospital doctor, a home visit from
■ In order to devise the appropriate strategy for each
a nurse to encourage support from family members,
individual you need to start by exploring clients’ and small-group self-help sessions to help patients
health knowledge and beliefs related to the issue of to manage their problems.
concern, the stage of change they are at and what ■ Records are important for follow-up. They are most
outcomes they desire. Asking the client to describe effective if they are kept and owned by the
a typical day in relation to the behaviour is a useful individual concerned, for example in the form of a
approach. diary.
■ You need to be aware that clients may be resistant
■ Providing a supportive environment can be the key
to change. In these situations it is best to to success, so that people find it easier to change to
emphasise that it is the client’s personal choice and and maintain a healthier lifestyle.
that they are in control. At a later date you could
References
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207
Chapter 15
Working with communities
Summary
Chapter Contents
This chapter begins with a discussion of community-
Community-based work in health promotion 208 based work in health promotion and an overview of
the range of activities it may include. Some key terms
Principles of community-based work 209
and principles are explained before an examination of
Community participation 210 three particular ways of working with communities:
community participation, community development and
Community development 211
community health projects. Each of these includes an
Community health projects 214 exercise, and there is also a case study of a community
development project. The chapter finishes with a
Developing competence in community work 219
consideration of the competencies health promoters
need to work effectively with communities.
See Chapter 2, section on defining health promotion.
As discussed earlier, health promotion is the process

of enabling people to increase control over, and
improve, their health (World Health Organization
1986). The challenge this presents is considerable
when working with people in the community who
may be disadvantaged and discriminated against,
and who may feel powerless to do anything about
their health. This chapter is about working with
communities in a way that enables them to take
more control over their health.
See Chapter 7, section on local health strategies and
initiatives, for information on government-funded
initiatives focusing on disadvantaged communities.
social units larger than a household. Essentially, a

Community-Based Work in
community is a network of people. The link between
Health Promotion
them may be:
Community-based work in health promotion ● Where they live (such as a housing estate or
involves working with groups of the public in a neighbourhood).
sustained way which will enable them to increase ● The work they do (such as the farming
control over and improve their health. It may community or school community).
involve different kinds of activities, including: ● The way they live (such as new-age travellers
● Community development work. or homeless people).
● Setting up a group and working with members ● Common interests or shared values (such as a
on health issues (such as a group with learning church community).
difficulties addressing issues of sexual health). ● Other factors they have in common (such as
● Working on projects or campaigns focusing on sexual preferences, so the gay community).
a particular community-identified health need The people in the network come together on the
(such as drug misuse). basis of a shared experience or concern, and iden-
● Outreach work, which means health promoters tify for themselves which communities they feel
going out to meet people where they are, rather they belong to. Networks may be formal or
than expecting people to come to them (such informal and since the advent of the Internet, the
as community work on sexual health, which concept of community no longer has geographical
might involve working with people in the sex limitations, as people can now virtually gather
industry on the streets or in clubs and massage in an online community and share common inter-
parlours). ests regardless of physical location (see http://
● Providing health information services (such as en.wikipedia.org for a full discussion of the nature
well-women information centres). of community from a range of disciplinary
● Health-related work undertaken by perspectives).
organisations with wider remits (such as health
courses for older people run by national older Community work
people’s organisations).
● Advocacy projects (such as organisations This means working with community groups and
undertaking interpreting and/or advocacy for organisations to overcome the community’s prob-
Asian women). lems. Community work aims to enhance the sense
● Self-help groups getting together for mutual
of solidarity and competence in the community. For
support on health problems. example, a community development worker may
take on a health promotion role by working with
This list (adapted from London Community Health particular communities in order to collectively
Resource and National Council for Voluntary bring about social change and improve quality of
Organisations 1987) begins to identify the activities life. This involves working with individuals, fami-
that health promoters may engage with at a com- lies or whole communities to empower them to:
munity level, but first the key terms and principles
● Identify their needs, opportunities, rights and
involved in community-based work need to be
responsibilities.
clarified.
● Plan what they want to achieve, and take
appropriate action.
Key Terms ● Develop activities and services to improve their
lives.
Community (For more details see http://www.prospects.ac.uk.)
Traditionally a community is seen as a group of
interacting people living in a common location. The
Community health work
word is often used to refer to a group that is organ-
ised around common values and social cohesion This is community work with a focus on health
within a shared geographical location, generally in concerns, but generally health is defined broadly to
Chapter 15 Working with communities 209
include social and economic aspects, so that com- information on the types of projects that lead to
munity health work may encompass almost as community cohesion, community engagement and
broad a range of activities as community develop- community development.
ment work. Finally, it is worth mentioning that in the health
service the word community is often used as an
Community action adjective to describe anything that is not based in
hospital. Examples are community care, commu-
This means activity carried out by members of the nity nurses and community services.
community under their own control in order to
improve their collective conditions. It may involve
campaigning, negotiating with or challenging Principles of Community-
authorities and those with power. Based Work
Community participation There are four key principles, as follows.
This is about involving the community in health

work that is led by someone outside the commu- 1. The centrality of the community
nity; for example a worker employed by a statutory It is the community which defines its own needs.
agency. The degree of participation may vary. Community-based work is essentially a bottom-up
process, rather than being top-down expert led
Community development where those with power and authority make the
decisions. Health promoters recognise and value
This means working to stimulate and encourage
the health experience and knowledge that exists in
communities to express their needs and to support
the community, and seek to use it for everyone’s
them in their collective action. It is not about dealing
benefit. Both legislation and policy recognise the
with people’s problems on a one-to-one basis; it
importance of community involvement in their
aims to develop the potential of a community as a
own affairs (see Department for Communities and
whole. A community development approach to
Local Government 2006).
health involves working with groups of people to
identify their own health concerns, and to take
appropriate action. Community development 2. The facilitator role of community health
health workers are essentially facilitators, locally promoters
based, whose role is to help people in the commu-
Community health promoters do not perceive
nity to acquire the skills, knowledge and confidence
themselves as experts in health, but as facilitators
to act on health issues. They are usually community
whose role it is to validate, encourage and empower
workers by background, rather than health
people to define their own health needs and to meet
professionals.
them. They start where the community is, recognis-
ing and valuing people’s own abilities and experi-
Community health projects ences. They involve people in community health
work from the very beginning, encouraging and
This is a loose term applied to programmes of work
supporting them in working together. Knowledge
that are organised by agencies for the improvement
and skills are shared and demystified. Community
of health in a community, or to local organisations
health promoters aim to complement as well as
aiming to improve health by supporting some com-
challenge statutory services by making people’s
bination of community activity, self-help, commu-
access to statutory agencies easier, and making the
nity action and/or community development. To
agencies more accountable to the people they serve.
read more on terms and projects linked to the com-
munity go to the Community Development Foun-
dation (CDF) website (http://www.cdf.org.uk). 3. The importance of addressing inequalities
The CDF is the leading source of community devel-
See Chapter 1, section on inequalities in health.
opment expertise and delivery. As a public body
and a charity it bridges government, communities A central concern in community-based health pro-
and the voluntary sector, and has a range of motion work is the need to challenge and change
the many forms of disadvantage, oppression, dis- concept of empowerment. Partnership, public par-
crimination and inequalities that people face, and ticipation and public decision making are all key
which adversely affect their health. issues in health services and local authorities.
Work therefore has focused particularly on the However, in reality some organisations may make
needs of disadvantaged groups. A central way of decisions without having any wish to engage with
working is to bring people in such groups together the public (see Scriven 2007 for a detailed overview
for support and information sharing, and to enable of collaboration and partnership working with
them to bring about change through collective communities).
action. The work can be political, because it often
involves working towards equality, social inclusion
and social justice with people who experience Community Participation in Planning
powerlessness and inequality as part of their every See also Chapter 6, section on public views.
day lives.
The amount of community participation in plan-
ning health work organised by an agency (such as
4. A broad perspective on health an NHS organisation or local authority) can vary
Health is perceived broadly and holistically as posi- along a spectrum of none to high, as shown in Table
tive wellbeing including social, emotional, mental 15.1. In the health service, such participation can be
and societal aspects as well as physical. It is not seen called public involvement or service user involve-
merely as the absence of disease, and is not limited ment. (See Rosato et al 2008 for an interesting dis-
by medical or epidemiological views of what con- cussion on the value of community participation for
stitutes a health problem or issue. Health is seen to health outcomes and Coulthard et al 2002 for an
be affected by social, environmental, economic and overview of people’s perception of community
political factors. participation.)
Ways of Developing Community

Community Participation
Participation
Participation is a word that is used widely to mean Community participation can be encouraged and
a range of activities, from those that are merely supported in many ways at different levels. If you
tokenistic to those which are firmly rooted in the work for a public sector agency such as a local
Table 15.1 Community participation in planning health promotion work
No participation The community is told nothing, and is not involved in any way
Very low participation The community is informed. The agency makes a plan and announces it. The community is convened or
notified in other ways in order to be informed; compliance is expected
Low participation The community is offered ‘token’ consultation. The agency tries to promote a plan and seeks support or at
least sufficient sanction so that the plan can go ahead. It is unwilling to modify the plan unless
absolutely necessary
Moderate participation The community advises through a consultation process. The agency presents a plan and invites questions,
comments and recommendations. It is prepared to modify the plan
High participation The community plans jointly. Representatives of the agency and the community sit down together from
the beginning to devise a plan
Very high participation The community has delegated authority. The agency identifies and presents an issue to the community,
defines the limits and asks the community to make a series of decisions that can be embodied in a plan
which it will accept
Highest participation The community has control. The agency asks the community to identify the issue and make all the key
decisions about goals and plans. It is willing to help the community at each step to accomplish its
goals, even to the extent of delegating administrative control of the work.
The table is adapted from Brager & Sprecht (1973). See also Scriven (2007).
authority or the health service, the following councillor’s surgeries (for an example see http://
suggestions may be useful (adjusted from Adams www.stockton.gov.uk).
& Smithies 1990 and Labyrinth Consultancy Provide support, advice and training for community
2000). groups. Provide opportunities for lay people to
Be open about policies and plans. Publicise your develop their knowledge, confidence and skills.
policies, invite comments and recommendations on CommunitiesUK have developed a guide for this
your plans, and involve representatives on plan- purpose, Community Power Pack: Real People, Real
ning and management groups. This is an intrinsic Power (Communities and Local Government and
part of policy. See, for example, Department for Involve 2008), which is online (http://www.
Communities and Local Government (2009), the communities.gov.uk) or can be ordered free.
government response to the White Paper Communi- Provide information. Provide information about
ties in Control: Real People, Real Power (Department health issues, details of useful local and national
for Communities and Local Government 2008). This organisations, leaflets, posters, books and
White Paper is about passing power to communi- websites.
ties and giving real control and influence to more Provide help with funding and resources. Help local
people. groups to obtain funding from statutory agencies,
Plan for the community’s expressed needs. When and provide other sorts of practical help such as a
planning health promotion services, help the com- place to meet or facilities to photocopy materials.
munity to express its own needs. Provide help with evaluation. Being able to show
Decentralise planning. Set up planning and man- real changes in community resources, services and
agement of health promoting and allied services on health outcomes increases respect and confidence
a neighbourhood basis, encouraging and enabling from communities, funders and agencies.
the public’s involvement. Support advocacy projects. Support projects that
Develop joint forums. Develop joint forums, such enable people who are otherwise excluded to have
as patient participation groups in doctors’ practices, a voice, such as mental health advocacy schemes
where lay people and professionals can work (see Foley & Platzer 2007).
together in partnerships. Mental health services Exercise 15.1 offers the opportunity for you to
often have joint forums to involve service users in consider how you can encourage community par-
service development. ticipation in your work.
Develop networks. Encourage individuals or
groups to come together, thus increasing their col-
lective knowledge and power to change things.
Value interagency links and gain the support of Community Development
workers from different organisations because com-
petition and lack of understanding of each other’s However much you might seek people’s participa-
roles and cultures can hinder progress. tion, it may be that they feel so alienated, dissatis-
Use electronic networking. Electronic networks fied or overwhelmed with problems that they reject
can provide community information and a means participation. In this situation, it is necessary to
of communication within and between commu develop a climate and culture where participation
nities (see http://www.partnerships.org.uk). For can happen. You need to encourage, enable and
example, rural communities with poor transport support people, and community development is a
facilities can use electronic networks (e-mail and way of doing this. Evidence suggests (although
websites), which go some way towards addressing measurement is difficult) that encouraging auton-
the problem of social exclusion caused by lack of omy, strengthening social networks and other
information. Not only can groups and individuals aspects of social capital are prerequisites for good
find and supply information on the Internet, health (Morgan & Swann 2004).
they can participate in democratic processes. For Community development is much more than
example, Communities UK uses Twitter (http:// community participation. It means working with
www.twitter.com) as does the National Council for people to identify their own health concerns, and to
Voluntary Organisations (NCVO). Many organisa- support and facilitate them in their collective action.
tions also use YouTube (http://www.youtube. It means adhering firmly to the principles of
com). Another example is the use of virtual community-based work outlined above, with the
EXERCISE 15.1 Developing community participation in your health promotion work

Consider the following list of ways in which you can To what extent do you think these things are
encourage community participation in working for health. desirable?
■ Be open about policies and plans. To what extent do you do these things already?
■ Plan for the community’s expressed needs. From this list, can you identify ways in which you
■ De-centralise planning. would like to increase community participation
■ Develop joint forums and networks. in your work?
■ Offer support, advice and training for community Can you identify any other ways in which you
groups. would like to increase community participation
■ Provide information. in your work?
■ Provide help with funding and resources. Given that there may be some obstacles to doing
■ Provide help with evaluation. what you would ideally like to do, can you
■ Support advocacy projects identify a practical way forward for acting on at
(If you are not sure what is meant by these, look back at least one of the things you would like to do?
the explanations above.) Work individually, in pairs or small groups.
EXERCISE 15.2 Thinking about community development

Working individually, or in pairs or small groups, work through the following questionnaire. If you are working with other
people, discuss the reasons for the answers you give. You do not have to reach a consensus. When you have listened to
each other’s views, you can agree to disagree.
Tick whether you think each of the following statements is true or false:
Community development is about: True False
1. Fostering a sense of community among people.  
2. Helping people to see the root causes of their ill health.  
3. Enabling a statutory authority to show it cares.  
4. Getting involved in a political process.  
5. Doing away with experts and professionals.  
6. Confronting forms of discrimination such as racism and sexism.  
7. Saving money on services by helping people to help themselves.  
8. Promoting equal access to resources such as health services.  
9. Enabling a community worker to become a leader/spokesperson for the community.  
10. Helping people to develop confidence and become more articulate about their needs.  
11. Campaigning for a better environment such as improved housing, transport and play facilities.  
12. Controlling social unrest, by providing, for example, activities for bored young people.  
13. Helping people from lower socioeconomic groups to change their attitudes and behaviour.  
14. Recognising and valuing the skills, knowledge and expertise of individuals and groups in the  
community.
15. Beginning a process of redistributing wealth, power and resources.  
Now add any other points you think community development is, or is not, about.
(Adapted from a questionnaire by Adams & Hawkins (undated and unpublished) and reproduced by kind permission).
community development worker having the role of Case study 15.1 illustrates community develop-
a facilitator. ment in practice, demonstrating how the commu-
Exercise 15.2 is designed to help you to consider nity and the community’s own expressed needs
what community development work means in were central, the workers acted as facilitators, in
practice. equalities in health were addressed and a broad
CASE STUDY 15.1 BE WELL

Be WELL Community Health Project came into being ■ Fostering and facilitating a two-way exchange
as a result of the vision of a group of people working between service planners and local people.
in the area who were concerned that local people At Be WELL, a wide range of services is offered and a
should be involved in determining their own health changing programme of activities which include:
needs and participating in defining what could ■ Drop-in – 3 days a week. One day includes
contribute to their enhanced health, wellbeing and activities such as crafts and storytelling. The
social functioning. drop-in is run by volunteers who provide tea
Be WELL operates from two refurbished former and healthy snack lunches. Project users have
council houses and is often referred to by local people the opportunity to enjoy a warm, welcoming and
as The Healing House. The project is open to anyone supportive environment.
living in Craigmillar (Scotland) or who is registered ■ Complementary therapies – acupuncture,
with a Craigmillar GP. reflexology, therapeutic massage, craniosacral
The project aims to provide a community health therapy and kinesiology.
resource, operating on community development ■ Counselling service – open-ended, person-centred
principles, where local people can meet to: counselling by trained volunteer counsellors.
■ Draw on the support and strengths of the ■ Groups and short courses – communications skills,
community. confidence and assertiveness, relaxation,
■ Explore their health issues and concerns. breastfeeding support, café and line dancing.
■ Formulate a collective response to those concerns. ■ Men’s group – self-support group, offering a
■ Develop a creative and responsive range of services meeting place for men which they decide how
and activities which local people have identified as to use.
enhancing physical, emotional and social wellbeing. ■ Heart to heart group – nonmedical source of
Be WELL also aims to help improve the health of the support, information and encouragement to people
community and address health inequalities both suffering from, or recovering from, heart disease or
locally and in a wider context by: surgery.
■ Working with a range of local, city-wide and ■ Free crèche.
national agencies in a collaborative, multiagency or ■ Annual stakeholders’ away day.
partnership way as appropriate.
(Adjusted from http://www.lchpf.co.uk/bewell.htm. See website for full details and more case studies.)
perspective on health was taken. It also shows how government targets with lifestyle risk factors for
local people were empowered to take action. major illnesses, and low uptake of health services
dominating the agenda. Community priorities, on
the other hand, may be about social conditions,
Some Implications of the Community
such as poor housing and lack of good public trans-
Development Approach
port. Conflicting agendas must be clearly under-
If you choose to adopt a community development stood and dealt with at the outset of any community
approach, it is important to appreciate the implica- development work.
tions and that areas of tension are likely to surface.
These are identified below, as are suggestions for
trying to prevent them.
2. Threat to local health workers
If local people gain confidence, become assertive
and more articulate through the process of com-
1. Different priorities and agendas
munity development, they could voice concern and
Priorities chosen by communities may not be the criticism about local health services. Furthermore,
same as those of local statutory agencies or the the prospect of members of the community taking
funding organisation. For example, health priorities an active role in policy making and planning may
for health promoters may be influenced by be alien to many managers in statutory agencies. A
thorough educational grounding in the rationale as self-help, community action and/or community
and principles of community-based work is development. Considerable insights can be gained
required, although setting this up and getting from existing community health projects; some
people to listen may in itself be a difficult task. have been written up to include the processes, out-
comes and lessons learnt. See, for example, the
website of Lothian Community Health Projects
3. No instant results
Forum (http://www.lchpf.co.uk), which is where
It takes time to get to know a community and to Case study 15.1 originated.
build up trust with local people, and it may be years
See Chapter 5, Planning and evaluating health
before there is any tangible outcome. A common
promotion.
problem is that projects with fixed-term funding for
a year or two are often expected to achieve substan- It is important to adopt a systematic approach to
tial outcomes in these short timescales, which is planning a community health project. Fig. 15.1 sum-
unrealistic. Secure long-term funding, with achiev- marises the planning and evaluation flowchart
able objectives, is fundamental to success. taken from Chapter 5, highlighting issues relevant
to community health project work. This is not a
comprehensive guide to setting up and running
4. A token gesture or an easy option
community health projects; it is intended to be com-
Well-meaning authorities who prioritise inequali- plementary to the information in Chapter 5.
ties in health may consider a community health
project as a way of addressing the issue. The in
equalities issue is complex, involving deeply rooted
Stage 1. Identifying needs and priorities
causes of poor health; a community health project At this stage, two particular issues are: how do you
can make a valuable contribution, but it can also get to know the community and who do you
divert attention from political solutions to the consult?
problems. Getting to know the community and its needs. Get all
the relevant information you can about the health
of the community. Search out data from local health
5. Evaluation conflicts
services and the local authority.
Outside agencies may expect to see results in terms Try contacting neighbourhood centres, commu-
of normative outcomes such as improved immuni- nity groups, voluntary organisations and tenants’
sation rates, a measurable change in community associations. People who might be able to put
behaviour (less binge drinking, vandalism or crime, you in touch with these include local workers in
for example) or lower rates of hospital admission. health and social services, local churches and
However, the objectives of a community develop- schools, the local Council for Voluntary Service and
ment project are rarely couched in such terms, and the local Council for Racial Equality. Talk to
are more likely to be concerned with far less easily members of the public, perhaps at local markets
measured results such as increased public partici- and festivals, or conduct a small survey. It might be
pation in health planning, or better communication necessary to hold public meetings to elicit full
between the community and statutory agencies. participation.
Open debate about the process, principles, aims Talk to local professionals, but bear in mind that
and possible outcomes is essential (see Green & professional perceptions will often stem from a
South 2006 for an excellent discussion of evaluating problem-centred view of a locality: for example,
community-based projects and ASH Scotland 2003 police may talk about crime, and social workers
for an example of evaluating a specific community about the numbers of children on the at-risk
project). register.
Local newspapers are a useful source of informa-
tion about the needs, interests and activities of a
Community Health Projects locality, and may even have a library service
to select material on a particular issue for you.
A community health project aims to improve health Another approach is to walk, not drive, around the
usually by combining a number of approaches such neighbourhood. Groups of young people on street
1. Identify needs and priorities

Consider how you will get to know the community and who you will consult.
2. Set aims and objectives

Work with the community to define aims and objectives.
Be flexible: community work is developmental, and you will need
to review and possibly change your objectives as you go along.
Be realistic about what you can reasonably expect to achieve.
3. Decide the best way of achieving the aims

Consult, be flexible and realistic.
4. Identify resources
Think about funding to support work in the long term as well as initial funding to get going.
Think about people as a resource: their collective energy, ideas and expertise.
Think about their development needs.
Think about appropriate premises.
5. Plan evaluation methods

Think this through carefully: what, why, who and how are you going to evaluate?
What will you do with the findings?
Look at both process and outcome.
Recognise that you may be assessing small changes over a long period of time.
6. Set an action plan

Do this step by achievable step, in a realistic time frame.
You need to consider consultation, and project/project worker management.
7. ACTION! Implement your plan, including your evaluation

You may need to consider ways of keeping going if interest flags, how to keep on course
if you feel you've lost your way, and how to wind up when the work is finished.
Fig. 15.1 Flowchart for planning and evaluating health promotion, with special reference to community health work.
corners, smells from fast-food shops and the range stage and also elicit community participation so
and price of goods in shop windows can reveal a that they have ownership of the project. Only do
lot about local lifestyle and socioeconomic this if you are confident the project is likely to
conditions. secure funding, as you could raise community
Consulting before setting up. Consult with local members’ expectations falsely and diminish
health and social service workers at a very early their trust.
Stages 2 and 3. Setting aims and help in understanding what this type of work is all
objectives, and deciding the best way about.
of achieving them Premises. You need to consider what premises
you need: rooms for large and small meetings, a
Key issues here are about being flexible and realis- room for a crèche, a place to keep and use equip-
tic. It is important to have full participation from ment such as video equipment and photocopiers, a
the people you have already made contact with, library/place where people can look up informa-
and the management group/steering group of the tion and use computers with access to the Internet
project (if there is one). These people are vital to and e-mail. Is there access for wheelchairs, push-
setting realistic, achievable aims and objectives, and chairs and prams? Running water and toilets? Facil-
working out the best means of achieving them. ities for making refreshments or meals? Good access
Flexibility is vital because community health by public transport? Well-lit premises so that people
work is essentially a developmental process, so you feel safe going there after dark?
need to review and, if necessary, modify your objec- You also need to consider the nature of possible
tives regularly. Objectives may change, and indeed premises. If you are offered space in a clinic, for
should change, if new opportunities arise and/or example, this may mean that people perceive the
previous objectives no longer seem achievable or project to be part of the statutory health services.
compatible with changing needs. Webpage. Many community health projects now
Be realistic: this applies to identifying what you have webpages (such as http://www.lchpf.co.uk),
plan to achieve, and when. For example, if you are so it is important to consider who will fund and
planning a community development approach, develop this resource.
ensure that you have a realistic time scale; 3 years
is suggested as a reasonable minimum.
Stage 5. Planning evaluation methods
It is vital that evaluation is planned at the outset, as
Stage 4. Identifying resources this will avoid misunderstandings and false expec-
Funding. Funding can come from statutory tations. All parties (funders, managers, workers,
organisations, such as the local authorities or the participants) need to agree on key issues:
health service, sometimes in partnership. Projects ● Why are you undertaking an evaluation? Who
may also be funded from the voluntary sector and what is it for?
through funding from government grants and ● What will you be evaluating?
independent funds, such as the Big Lottery Fund ● How will you do it? What methods will you
(see http://www.biglotteryfund.org.uk for the full use?
range of Reaching Communities funding, and also
● Who will do it? Will you evaluate yourselves or
for case studies and evaluation reports). Uncertain
will you use someone who is not involved in
funding arrangements can increase difficulties in
the work as an external evaluator?
planning and evaluating work and can divert
● Who will be involved in the evaluation
efforts from project work to fundraising. It is impor-
tant to think about long-term funding, otherwise process? Will it involve the community, the
there is a danger of work being dropped when workers, the funders, the steering group?
funding runs out. ● What will you do with your evaluation
People. By bringing people with a common inter- findings? Will you publish a report? Who will
est or experience together, you may find that the be responsible for publication? Who will the
collective energy of the group generates ideas for evaluation report be distributed to? Who will
future action. Your role may also begin to change, own it? Will findings be widely disseminated,
from being an initiator/facilitator to being a such as in journal articles?
supporter. (Based on ideas in DeGroot 1996.)
It is also important to think about what training Identify evaluation conflicts and ensure that your
and development is needed, who will do it and how evaluation looks at process, impact and outcome,
it will be funded. Not only project workers but also and identifies realistic ways of assessing what may
the project management committee (if there is one), be very small changes over long periods of time. It
local lay people and health professionals may need will probably not be possible to evaluate every
element of a project so it may be necessary to pri- included. For example, does the job include fund-
oritise which elements will be assessed. raising, doing your own typing, servicing or even
It may be helpful to think in terms of charting running the management committee meetings,
changes as they occur, using a framework to record keeping the accounts, evaluating, writing progress
these systematically. An example of this approach reports?
is the outcome measures checklist used in a com- Ensuring support for the project workers. Recognise
munity health project described in Case study 15.2. the value of networking as a means of informal
training and support. Networking requires making
time and other resources available to meet people
Stage 6. Setting an action plan
doing similar work and to link with other commu-
There are many things to consider here, but the nity health projects in different parts of the country.
main one is to identify what you plan to do, step This enables information and ideas to be shared and
by step. problems discussed. Access to e-mail and the Inter-
You may need to build the following activities net is essential. The need to ensure that project
into an action plan: workers are not isolated is crucial.
Reviewing aims and priorities. It is necessary to Networking also means that more people will
review continuously the aims and priorities origi- know about the project and you may get more
nally set down for the project, and compare them support.
with those of the people who are now involved. You Formalising your project group. It may be helpful at
may need to modify the original aims, and regu- some stage to look at the costs and benefits of for-
larly check that the agenda is meeting community malising a project group that started off as a loose
needs. collection of interested people. The advantages of
Consulting and being accountable to the commu- having a formal organisation are that it can apply
nity. The community participation established at for financial help and for recognition as a legitimate
the outset needs to continue throughout. Once the body; the disadvantages might be that control could
project is established, you have a continuing respon- be exercised from outside. The local Council for
sibility to involve the community. This could be Voluntary Service can be extremely useful because
through meetings, newsletters, electronic networks it provides a helpful service for newly formed
and open days, for example. groups, and affiliation to the Council brings credi-
Arranging a management committee or steering bility in itself.
group. A management committee or steering group Dealing with opposition. The health issues the
should provide a secure foundation for the project, project is concerned with will probably have a local
taking responsibility for its continued develop- history, and be likely to have both won and lost
ment, its policies and management tasks such as support in the past. You need to identify opposition
fundraising and recruiting. It should also provide and plan a strategy for dealing with individuals or
support for the project workers. Usually these are groups who may oppose the project.
members of the group; they should not be expected
to run the management committee themselves, but
sometimes this is the case. This is not desirable Stage 7. Implementing your plan
because it leads to confusion about who is manag-
ing whom, and puts an unreasonable burden on the As the project is implemented, it may run into dif-
workers. ficulties because of a) flagging interest, b) lack of
A management group could consist of both local direction, and c) the project coming to an end.
workers, such as health visitors and social workers, Keeping going. Over time, the community may
and local people, perhaps representing the com- lose its enthusiasm. You may be able to provide
munity groups involved in the project. additional impetus by being involved as a whole
It may be helpful to get the members of a man- or part of your paid work. You need to be sensitive
agement committee/steering committee together to the many ways in which a project can lose direc-
for a day, to talk through the issues, clarify aims and tion, and in such circumstances you may be able to
foster a sense of teamwork. help by:
Writing job descriptions. Paid project workers ● Discovering what similar activities are taking
need clear job descriptions, specifying what is place elsewhere and circulating details.
CASE STUDY 15.2 A CHECKLIST FOR CHARTING CHANGES IN A COMMUNITY

A 3-year project ran on a housing estate where residents were identified as being at high risk for heart disease.
Using a community development approach, a community health promoter worked with local residents on issues
which residents identified as important. Over the life of the project, changes were noted, many of which became
embedded as permanent features in the community. These changes were charted in a systematic way, using the
following outcome measures checklist.
Type of change Information recorded Examples

Participation of target Numbers and characteristics (age range, Number and age range of young parents
population in health-related sex, etc.) of people who attend attending a new parent and toddler
action groups and community activities group
Perceived changes in Changes in attitude towards Action group set up by local people to get
knowledge, attitude and participation in group and better play facilities on the estate. Led
behaviour of target community activity; change in beliefs to establishment of local playgroup run
population about ability to have control over by local women. Many members stopped
one’s own life and the power of smoking
group action; changes in the
subjective experience of belonging to
a community; changes in the
capacity of local groups to identify
problems and collaborate to solve
these
Changes in demand for Changes in demand or requests for Groups requested talks from health visitors
health-related services services or facilities on health issues. Request for more
accessible primary healthcare facilities
on the estate
Changes in the availability of Changes in group and community New groups to support young single
support, facilities and activities, informal social and support parents. ‘Get Cooking’ group to help
resources for people wanting networks within the community people learn to cook healthier food for
to change lifestyle their family. Exercise group for older
people
Other physical changes to the Any changes to the built or natural Playground built. Traffic-calming schemes
environment environment introduced
Changes in knowledge, Changes in attitudes towards local Local health visitors use experienced local
attitudes, skills and practices residents to exercise choice and mothers to support young new parents
of local health and allied control over the services they receive,
workers or changes in ways of working
Changes in policy and Changes that enable local people to Consultation with local residents about
procedures by local statutory have more say in decisions about location and design of new GP surgery
and voluntary organisations local services on the estate
Dissemination of good practice What information was sent out and Article in community health journal.
why, talks, presentations, papers Community health projects featured in
published and any evidence that health authority public health report
good practice elsewhere has been
affected
Any other outcomes Any other outcomes, expected or
unexpected, which fall into the above
categories
(Based on Bruce et al 1996 and Ewles et al 1995, 1996.)

● Drawing the issue to the attention of relevant Leavings and endings. There comes a point when
statutory agencies, and conveying the response your involvement has to stop, maybe because you
to the group. change your job or the priorities of your work, or
● Helping the group to produce its own health because the project work has been taken on by local
promotion materials such as posters, leaflets, people. Occasionally, you will need to recognise
Web site or video, and distributing them. that you have done all you could do, and that there
● Looking at other health promotion material on is now no potential in the project. Ending your
topics of interest. involvement provides the opportunity for a final
● Encouraging members of the project to talk
evaluation of what has been achieved and what
about their work to other people, such as your own contribution has been, and for making
groups of interested professionals and students. recommendations for future action.
● Sending memos or e-mails to everyone to
remind them of meetings.
● Providing practical support such as
Developing Competence
photocopying or access to a computer.
in Community Work
● Introducing new members.
Working out what to do next. If you feel that you have To be a successful community health worker, you
lost direction, it can help to write down what infor- need a range of competencies. You will also need to
mation you have found, what contacts you have be committed to the principles and ideals of com-
made, what needs and aims you have identified munity-based work outlined earlier in this chapter:
and what you have done so far. Then seek the views the centrality of the community, your own role as a
of your management/steering group (if there is facilitator rather than an expert, the importance of
one) or the impartial views of someone who has not addressing inequalities and a broad perspective on
been involved. Exercise 15.3 may help to provide a health.
focus for working out what to do next.
See Chapter 1, section on inequalities in health and
Chapter 3.
EXERCISE 15.3 Planning community health In order to adhere to these principles, you will
promotion work need knowledge of key issues, such as the extent
The following exercise may be useful when you are and cause of inequalities in health, the effects of
starting community health work or taking stock part racism, sexism and other forms of oppression on
way through a community health project. health, and awareness of the structures, policies and
Complete the following statements as fully as you powers which influence the lives and health of com-
can: munities. You will also need to be clear about your
The key issue is … own particular political ideologies.
The people I need to consult/participate with See the section above on getting to know the
are … community and its needs, Chapter 4, section on agents
The documents I need to read are … and agencies of health promotion and Exercise 4.1, and
I can get to know more about the community Chapter 6, section on finding and using information.
by …
The information that is likely to be available is … Other areas of knowledge include familiarity
I intend to look for this information by … with local health resources: who and where to go to
Work done on this issue elsewhere is … for information, advice and materials on health
The people who are likely to be supportive are … issues. Knowledge of local health services and
The people I should avoid offending are … social services is vital; so is understanding how
The period of time I can spend on this issue is … local statutory and voluntary agencies work, and
The amount of time I can give it during this how to use the system effectively. An understand-
period is … ing of the community itself is of course vital.
The person/people I will consult/participate with A range of skills is required. It is important to
in order to work out what to do next are … have competencies in raising awareness of inequali-
ties and discrimination, and being able to counter
these by taking positive action when appropriate ■ A key principle is that community work is bottom
and working in an antidiscriminatory way. up, not top down. This means that you respond to
issues that the community identifies, rather than
See Chapters 5, 7, 8 for planning and managing; 10 for
working on issues identified by people outside the
communication; 11 for using communication tools; 13
community, such as health workers from statutory
for working with groups.
agencies.
Other skills link to working with people: being ■ Community health workers take on the role of
able to communicate well, facilitate groups and run facilitators rather than health experts, to develop
effective meetings. You also need skills of planning the community’s abilities to both identify and meet
and management, using and producing health pro- health needs.
motion materials, and working for political change ■ Work is often focused on addressing inequalities
(Smithies 1987, North Cumbria Health Develop- and working with people who are disadvantaged.
ment Unit 2001). ■ Health is interpreted holistically to encompass
social, emotional and societal wellbeing.
PRACTICE POINTS ■ Community participation is fundamental to health
planning and health promotion activity.
■ Community-based health promotion involves ■ You need particular skills and processes for
working with communities (rather than individuals) successful community development work and
over a period of time to enable them to increase community health projects. You need to be aware
control over, and improve, their health. It may of the potential conflicts and difficulties inherent in
involve community development work, specific this kind of work.
community health projects and group work.
References
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223
Chapter 16
Influencing and implementing policy
Summary
Chapter Contents
The focus of this chapter is on how health policy
Making and influencing local and national health at local and national level is made, how it can be
policy 224 influenced and how health promoters can challenge
health damaging policies. The characteristics of
Implementing national health policies at local
power and the politics of influence are discussed and
level 224
illustrated with a case study. There are sections on
Challenging policy 226 developing and implementing policies, a case study
on the politics of influence and an exercise on policy
Developing and implementing policies 228
implementation. The chapter ends with a section on
Campaigning 232 planning a policy campaign.
See Chapter 7, section on linking your work into broader

health promotion plans and strategies, for information
on national and local public health strategies and
plans.
Health promoters have an important role in

influencing and implementing policies that affect
health. A policy is a broad statement of the princi-
ples of how to proceed in relation to a specific issue
and can be at a number of levels, from international
(see Duncan 2002 for a debate on the way EU health
policy impacts on UK policy), to national, regional
and organisational level.
In order to influence policy you need to under-
stand how power is distributed and exercised
between people at various levels and be able to use
that knowledge to further your work and shape
policy decisions. In other words, you need to be
political.
Another relevant and important aspect of policy is
managing change, discussed in Chapter 8.
Being a policy activist involves working with environmental impact assessments of their services
statutory, voluntary and commercial organisations and related policies. The Association of Health
to influence the development of health promoting Observatories Health Impact Assessment gateway
policies. It also includes working for healthy public has many examples of HIAs at http://www.apho.
policies (see Scriven 2007 for a detailed overview of org.uk (see, for example, Health Inequality Impact
healthy public policies) and economic and regula- Assessment into the Leicester LIFT project). HIA
tory changes that might require campaigning, involves examining the impact on health and/or
lobbying and taking political action. the environment of all current and planned policies
and activities. The purpose is to develop practical
ways in which current health and environmental
Making and Influencing Local impact of services could be improved and to inform
and National Health Policy the development of a corporate approach to new
health and environmental policies.
Working for policy change is an integral part of
See Chapter 7, section on health impact assessment.
health promotion action, with health promoters
able to press for the introduction of policies at both
national and local levels and influence how they are
Health Policy in the Nhs
implemented. The development of local health poli-
cies cannot be divorced from the central govern- The task of commissioning health services and pro-
ment’s policies that shape the organisation and grammes was undertaken by health authorities
funding of health service, local authority and vol- until 2002, when it passed to PCTs. Commissioning
untary agency work at a local level. National policy health services means deciding what health serv-
is in turn influenced by consultation with and rep- ices, policies and programmes are needed to
resentations from health services, local authorities improve the health status of the local population
and voluntary agencies. and ensuring that they are provided.
Other bodies such as national health promotion PCTs provide opportunities for the public to
agencies and public health organisations such as comment on health service plans. There are repre-
the Royal Society for Public Health (http://www. sentatives of the public on PCT management boards
rsph.org.uk) are also highly influential in the field (usually called lay representatives) and PCTs gener-
of policy development. For an example of a national ally consult the public on any significant proposals
agency contribution to policy, see the report of the for policy change. Individuals, groups, professional
20-year legacy of the Health Promotion Agency associations and others are able to express their
(HPA) of Northern Ireland (HPA 2009). views on, for example, the balance of money spent
on treatment and care compared with health pro-
motion and disease prevention. Some PCT board
Local Health Policy members have responsibility for ensuring that the
At a local level, during the last decade healthy PCT properly addresses specific policy areas such
public policies and priorities have increasingly been as inequalities in health.
jointly agreed by health, local authority and volun-
tary agencies. This has been made easier through
national policy initiatives such as the implementa-
Implementing National Health
tion of local strategic partnerships (LSPs), where
Policies at Local Level
health and partner agencies are required to deliver
joint plans for health and wellbeing. This means
National strategies for health are outlined in detail in
that policies have to be agreed by local authorities,
Chapter 7, and referred to in Chapters 1 and 4.
primary care trusts (PCTs) and other relevant com-
munity organisations. National strategies for health have been in place
since the early 1990s with targets that set specific
The structure of the NHS, including PCTs and strategic
health outcomes. PCTs and partner agencies from
health authorities, is outlined in Chapter 4; see Figure 4.2.
the public, private and voluntary sectors translate
Some health organisations and local authorities these national targets into local ones, and may add
undertake health impact assessments (HIAs) or other local targets. These targets, and the priorities
Chapter 16 Influencing and implementing policy 225
and objectives they are derived from, are an impor- governments at international levels, which focus on
tant influence on policies and on health promotion ways of achieving sustainable development in rela-
programmes and activities. tion to the environment and the wider determi-
For example, the National Service Framework for nants of health.
Coronary Heart Disease (Department of Health (DoH) Local authorities have to work with a broad
2000a), a policy document setting out the standards range of agencies and consult their communities
for services about prevention and treatment, has about developments in relation to implementing
national targets for reduced death rates and changes international polices at a local level. Health promo
in risk behaviour, such as smoking. These targets ters, in both their working role and their role as
are translated into local targets that include health private citizens, can play their part.
promotion programmes on smoking prevention,
such as providing smoking cessation help as part of
maternity services. In this way, national policies The Voice of the Consumer
and strategies influence directly local interventions. in the Nhs
For an assessment of the impact and progress
toward implementing the Coronary Heart Disease In The NHS Plan (DoH 2000b) the government made
National Service Framework in the 8 years since its a clear commitment to being responsive to the
publication, see DoH 2008. needs of all citizens by allowing their voices to be
heard in relation to health-related public policies,
See also Chapter 7, section on local health strategies planning and provision of services.
and initiatives, for more on local plans and strategies. A number of steps have been taken to enable
consumers to express their views. One example of
this is the NHS Constitution for England (DoH
Local Authority Contribution 2009) which makes important pledges in relation to
to Health Policy how people access NHS services, what commit-
The local authority contribution to health policy is ment people can expect from the NHS and what
made at a strategic level through LSPs and the their rights and responsibilities are in terms of influ-
development of local area agreements (LAA). LAAs encing policy and service provision. A patient
simplify some central funding, help join up public advice and liaison service (PALS) (http://www.
services more effectively and allow greater flexibil- pals.nhs.uk) was set up in every NHS trust for
ity to develop policies to meet local health needs patients to get their concerns addressed. Other
(for further details on LAAs, see http://www.com- measures introduced to ensure that citizens and
munities.gov.uk). patients have more influence at all levels of the
LSPs bring together people from the public, NHS include:
private and voluntary sectors. They aim to avoid ● Increased lay representation, such as on
duplication and to rationalise partnerships and the National Leadership Network for
plans to make it easier to deliver policies around Health and Social Care (http://www.
health improvement, education and crime. The nationalleadershipnetwork.org) and the Care
Neighbourhood Renewal Strategy (Social Exclusion Quality Commission (http://www.cqc.org.uk).
Unit 2001) is a catalyst for these partnerships and See Voices into Action (Care Quality
plans and has a direct impact on health gain (see Commission 2009) for details of how lay voices
Leathard 2003, for a critical overview of the link are heard.
between NHS LSP and community strategies). ● A new Citizens’ Council, to advise the National
Institute for Health and Clinical Excellence
See also Chapter 7, section on local health strategies
(NICE). The Citizens Council brings the views
and initiatives, for more about local plans and strategies.
of the public to NICE decision making about
Another important way in which health services guidance on the promotion of good health and
and local authorities can work together at local level the prevention and treatment of illhealth. A
is through cooperating in implementing inter group of people drawn from all walks of life,
national agreements such as the UN Agenda 21 the Citizens Council tackles challenging
and Millennium Development Goals (http:// questions about values, such as fairness and
www.un.org). These are agreements forged by need (http://www.nice.org.uk).
While the means for lay involvement are in place, who share your concern to improve health and
a recent review by the government select committee challenge health damaging policies. For
on health (House of Commons Health Committee example, members of the UK Public Health
2009a,b) suggests that there is a risk the NHS Association (UKPHA) aim to widen the focus
may still not be engaging the public in a meaningful of health policy in the UK towards creating a
way. healthy environment, reducing inequalities and
improving quality of life.
Challenging Policy However, many areas of policy development are
not controversial, and can be a positive and reward-
As a heath promoter you may find you are expected ing part of the day-to-day work of health promo
to implement policies that you perceive as health ters. The main thrust is likely to be in developing,
damaging or contrary to health promotion princi- changing and implementing local policies. To do
ples. This can be difficult because such policies can this you need to understand the characteristics of
emanate from national government or your employ- power and influence and be competent at exerting
ing organisation or even your direct manager. To influence when necessary.
challenge may create a conflict of loyalty between
wanting to press for what you see as right and what
Characteristics of Power
is decreed to be right by your employing authority.
and Influence
To protest may be seen as too political. There is no
easy answer to this issue, but there are some posi- Power is the ability to influence others. There are
tive steps worth considering. four generally recognised types of power that are
● Use your vote. At the next general or local relevant to health promotion work:
election, look at the health implications in the 1. Position power is the power vested in someone
policy manifestos. Raise questions about health because of their position in an organisation. For
policy with doorstep canvassers, at public example, a Director of Public Health has
meetings and by writing to candidates. All this position power.
can be done in your capacity as a private 2. Resource power is the power to allocate, or
citizen rather than a health worker. limit, resources, including money and staff. It
● Use your professional association or trade often goes hand-in-hand with position power.
union. These groups can raise issues at a For example, a senior health service manager
national and local level, and can be a powerful has both position power and the power to
voice. You can play your part by joining and regulate the use of resources. You have a source
supporting their activities, and raising the of power if you have the authority to control
issues you feel strongly about. the allocation of any resources. Every health
● Use your representative. There are many promoter will have some power because people
people whose job is to represent your interests. want the skills or services on offer.
At European Union or national level, it is your 3. Expert power is power related to expertise.
Member of the European Parliament (MEP) or Directors of Public Health have the expert
your MP. So if you want to raise an issue at power associated with their specialty.
these levels, lobby your MEP or MP: send 4. Personal power is the power that comes from
letters, telephone, attend politicians’ surgeries. the personal attributes of a person, including
At local level, do the same with your local strong personality, charisma and ability to
councillor. You could also contact your inspire. It is closely related to leadership
professional association or union local branch qualities and intelligence, initiative, self-
representative. confidence and the ability to rise above a
● Use your collective power. If you are situation and see it in perspective. However,
concerned about an issue at your place of work, effective leaders are not always charismatic,
it may help to find out if colleagues feel the and what makes a leader effective in one
same. If they do, join together so that you raise situation may cause them to be less effective in
the issue collectively: this can give it more changed circumstances. The classic example of
impact. Or at a national level, join with others this is Sir Winston Churchill. The attributes that
made him effective in wartime were not so They are obviously powerful forces in the situation.
appropriate in peacetime. It could be difficult to identify all the stakeholders,
You may sometimes be in the position of wanting because some of them may not wish to be visible
or needing to exert influence on people who have a and try to work covertly through others.
stronger power base. For example, a health visitor Time your action. It is also important to consider
may wish to influence a general practitioner to when to introduce a proposal or when to delay. If
adopt a policy of supporting the running of ante people are already preoccupied with other major
natal clinics in the local ethnic minority group’s issues, it might not be the right time to make a new
community centre, or a community worker may proposal. On the other hand, if a proposal will help
want to lobby local councillors about the need for other people to attain their own objectives, it will
more recreational facilities for young people on a be a good time.
housing estate. To do this requires skills in influenc-
ing and negotiation (see Cialdini 2007 and 2008 for Making allies
overviews on the science and practice of influence
and the power of persuasion). Identify which of the stakeholders could be allies,
Before attempting to influence someone who has and gain their trust and confidence in order to
position or resource power, first consider the basic establish and maintain an alliance. It helps to pay
questions in the planning process, such as: What are attention to their concerns, values, beliefs and
your aims? What resources do you need? Is the behaviour patterns, and to see what you need to do
investment of your time in influencing others going in order to form an effective working alliance.
to be worth it? Could the aim be achieved more For example, if you are concerned about the way
easily another way? in which people with disabilities are treated in an
organisation, you might identify the person in
See Chapter 5, Planning and evaluating health charge of human resources as a key stakeholder. So
promotion. find out if they are concerned about it and if they
think it is important for the organisation. What kind
The Politics of Influence of way do they work, are they likely to respond best
to a lively discussion on the subject or to a well
There are four key elements of a strategy aiming to
argued paper on the need for policy, backed up
change policy:
with facts and figures? Do they like time to make
1. planning decisions? Will they be happy to leave you to take
2. making allies the lead, or will they want ownership of the
3. networking initiative?
4. making deals and negotiating.
Networking
Planning Many people working in organisations belong to
Three particular aspects of planning are useful to one or more interest groups who meet to discuss,
consider: undertaking a force field analysis, identi- debate and exchange information on issues that
fying stakeholders and considering your timing. concern the members. By playing an active role in
Undertake a force field analysis. A force field analy- these networks, people can extend their influence.
sis identifies the helping and hindering forces and Networks provide access to information that can
helps to pinpoint how you can influence the process help with making a case, to people with experience
to make progress towards change. You identify how of successful influencing, and to other resources.
you can increase the power of the helping forces There are different types of networks:
and decrease the power of the hindering forces. Professional networks. Members are from the same
profession. Professional networks may attempt to
There is an example of a force field analysis at the end
influence employers and organisations to recon-
of Chapter 4, Exercise 4.2.
sider their policies or to develop new policies for
Identify the stakeholders. The stakeholders are the future. Professional networks institute criteria
those people with a vested interest in the issue, who for professional practice and are active in the pro-
wish to influence what is done and how it is done. fessional development of their members.
Elitist networks. Members of an elitist group can it results in failure to make a realistic appraisal of
join by invitation only. The network operates by situations, and failure to make the best of the oppor-
personal contact and personal introduction. tunities for positive health promotion. Furthermore,
Members of such networks may have considerable it is possible to be political without losing profes-
power and influence, often through their position sional integrity: for example, by ensuring deals are
in organisations. made as the outcome of open negotiations, and that
Pressure groups. Members wish to pursue certain relationships should be based on genuineness,
objectives, which may be environmental, social or trust, goodwill and mutual respect. Case study 16.1
political. In order to enter a particular network it offers an example of the politics of influence in
may be necessary to identify the gatekeepers who practice.
control entry, and other people who are influential
in the network and could act as a sponsor for
someone seeking to join. Having entered a network Developing and Implementing
it is important to support the values and established Policies
ways of working. Later, having been accepted, it
may be possible to challenge accepted practices. There are numerous kinds of health promotion poli-
cies. Many are about health issues that relate to
workplaces or other settings such as schools, com-
Making deals and negotiating
munities and hospitals. Other policies can be about
Making deals is common practice in most organisa- health issues in a range of contexts, such as a
tions. Individuals or groups agree to support a pro- national policy on teenage pregnancies, which
posal in return for agreement on something that would cover action across many different settings
benefits them. In order to make deals successfully, (Department for Children, Schools and Families
it pays to know the person with whom you are 2008). For some health issues, such as alcohol in the
dealing, paying careful attention to their values and workplace, it is common practice to have a policy
intentions and what you could realistically expect (http://www.alcoholpolicy.net).
from them.
Negotiation is the art of creating agreement on a
Policies on Promoting Health
specific issue between two or more parties with
in Workplaces
different views. Successful negotiation takes place
when there is a desire to solve problems and the The benefits of health promotion at work are well
parties genuinely commit to going through a established and reviews of the literature identify
number of steps. There are many guides on how to the major benefits as a decrease in absenteeism and
improve your negotiation skills. While these are staff turnover, and an increase in productivity and
mainly written for the business community, the morale (Fleming 2007). The European Network
skills are also relevant to health promotion. See, for for Workplace Health Promotion (http://www.
example, Hawver (2007). enwhp.org) has a range of publications that will
support policy development that encourages
employers and trade unions to take on a wider
On Being Political
concept of health at work, including giving priority
A final point is about political behaviour, which to issues such as smoking, alcohol and stress. The
refers to finding out about who holds power, and World Health Organization (WHO) also has a
working to use this information to change a situa- number of guidelines on supporting workplace
tion. When is it acceptable and when is it policy development on issues such as mental health
unethical? (for example, WHO 2005).
Being political can be considered devious and In the UK in 2008, the cross-government
manipulative. Some people may view it with sus- Work, Health and Wellbeing programme published
picion and will therefore not be easily influenced by Improving Health and Work: Changing Lives (http://
such behaviour. To manipulate covertly, or coerce, www.workingforhealth.gov.uk). It was the govern-
lie or deliberately withhold information that affects ment’s response to Working for a Healthier Tomorrow
others is unethical and unprofessional. But to ignore (Black 2008) and follows the launch in 2005 of the
the politics within organisations is unwise, because Work, Health and Wellbeing Programme, which is
CASE STUDY 16.1 THE POLITICS OF INFLUENCE – HEALTH AND SAFETY AT WORK
Bob is an environmental health officer working for He further identifies key stakeholders as:
Midshire City Council. His aim is to improve the ■ officers in the department of engineering because
implementation of the health and safety at work they enforce building regulations
policy of the council. He makes a list of the helping ■ council members on the health committee
forces and the hindering forces: ■ the director of personnel.
Helping: He then identifies ways of increasing the helping
■ the existing safety officers forces and decreasing the hindering forces. Through
■ existing codes of practice, for example sight checks making an ally of the interested human resources
for VDU operators officer he is able to increase the commitment of the
■ a councillor who is a health lecturer at the director of human resources, who is also a chief
university officer. One short-term outcome is that an
■ a human resources officer interested in improving occupational health nurse is recruited. Another
the working environment for staff outcome is a plan agreed by the human resources
■ an existing commitment to appoint an department and the trade unions for training staff in
occupational health nurse. health and safety.
Hindering: By joining a local network of people interested in
■ the cost of any improvements (the council has health promotion he is able to find out what is going
severe financial constraints) on elsewhere, and this gives him some useful ideas,
■ staff time to attend health and safety training including sources of help in stress management
■ problems with recruiting an occupational health training which he incorporates into the training plan.
nurse He makes a deal with the engineering department
■ deficiencies in the structure of council buildings by agreeing to assist with monitoring construction
(poor ventilation, open-plan offices, lack of sites of new buildings in order to prevent accidents
showers for those staff wishing to take physical on the site. In return, they agree to assist with a plan
exercise during the day) for improving soundproofing and modifications to
■ lack of councillors’ commitment to improve health open-plan offices. Their commitment grows after a
and safety conditions for staff report shows that accidents on construction sites are
■ lack of access to council buildings for disabled reduced. He discusses with them the issue of raising
people. with council members the plan for modifying council
He identifies the stakeholders as: buildings.
■ the staff themselves Finally, he makes an ally of the councillor at the
■ the trade unions university by offering to provide an input to some of
■ departmental managers, senior and chief officers the courses. This councillor is on the health
■ the councillors committee and provides him with useful advice on
■ the public health specialist and the health how to approach the committee and how to prepare
promotion specialist from the local PCT. documents for its consideration.
sponsored by five government partners: the Depart- governing health and safety in the workplace
ment for Work and Pensions, the Department of (http://www.hse.gov.uk).
Health, the Health and Safety Executive, the Scot-
tish Government and the Welsh Assembly Govern-
ment. Work, Health and Wellbeing is an initiative
Policies on Promoting Health
to protect and improve the health and wellbeing of
in Hospitals
working age people. It encourages workplace well-
ness policies through such tools as The Business Health Promoting Hospitals is a WHO initiative,
HealthCheck. designed to improve health and environmental
In the UK, the Health and Safety Executive is also conditions for both staff and patients by reviewing
a source of information on all statutory policies and implementing a range of health promoting
policies (http://www.euro.who.int). Many hospi- health promoting school initiative have some influ-
tals have taken up the idea of being a health pro- ence on various domains of health for the school
moting hospital, but it can be difficult in practice to community (Mükoma & Flisher 2004).
inform and involve everyone in an institution as
See Chapter 4, section on local authorities, for more
large and complex as a hospital (Whitehead 2004,
about health promotion in educational institutions.
Groene 2005).
The UK government’s commitment to the whole-
school approach to health is strong, as can be seen
Promoting Health in Urban Settings: from their support of the Healthy Schools pro-
Healthy Cities gramme, which has become one of the country’s
most widely embraced initiatives in schools.
The WHO’s Healthy Cities initiative promotes com-
Health promotion in the education sector also
prehensive and systematic policy and planning
covers higher education settings, such as universi-
with a special emphasis on health inequalities and
ties (Dooris 2002, Dooris & Martin 2002).
urban poverty, the needs of vulnerable groups,
participatory governance and the social, economic
and environmental determinants of health. It also
strives to include health considerations in eco- Policies on Promoting Health
nomic, regeneration and urban development efforts. in Prisons
It aims to work from the bottom up, not from the The WHO coordinates the Health in Prisons Project
top down, and to involve collaborative work (HIPP) (http://www.euro.who.int) to promote
between local government, health authorities, local health in prisons, and is working to develop an
businesses, community organisations and, of award scheme for health promoting prisons. See
course, individual citizens (http://www.euro.who. also Department of Health (2002) for the UK policy
int; see also Lawrence & Fudge 2007). on health in prisons.
See Chapter 15 for principles of bottom-up working.
For a useful overview of the effectiveness of
health promotion using a settings approach and
The Health for All (UK) Network is a coordinat- related policies see Dooris (2009).
ing body for action on Healthy Cities within the
UK (http://independent.livjm.ac.uk). The Healthy
Cities work in Belfast is a good example of what is Guidelines on Developing and
being achieved (http://www.belfasthealthycities. Implementing a Policy
com).
Many health promoters have a role in developing
and implementing polices in specific settings such
Policies on Promoting Health as those discussed above. An example is the work-
in Schools place alcohol policy outlined in Exercise 16.1. The
process of developing and implementing a health
The European Network of Health Promoting promotion policy involves four aspects: prepara-
Schools (ENHPS), now known as Schools for Health tion, implementation, education and training, and
In Europe (http://www.schoolsforhealth.eu), sets evaluation (adapted from Simnett & Chiles 1989
out to show that schools can be powerful agents for and Sheffield City Council Health and Consumer
change through the adoption of whole-school Services 1989).
approaches. This means that the school promotes
health not only by curriculum policies which
includes sufficient time for social, personal and 1. Preparation of the policy
health education for the pupils, but also by wider
school policies that ensure that the school promotes The formulation of a policy by any organisation is
a sense of positive self-esteem and the health and a corporate matter, so the usual starting point is to
wellbeing of teachers and other staff, parents and convene a working group. This group:
the wider community who have contact with the ● Clarifies its terms of reference and elects a
school. An evaluation found there was evidence Chair.
that the policies implemented as a result of the ● Identifies the need for a policy.
EXERCISE 16.1 A workplace alcohol policy

Westshire NHS Hospital Trust is encouraged by a national are still unenthusiastic, and one major change they make
sensible drinking initiative to develop a policy on alcohol alters the working group’s recommendations on
for its workforce. implementation. These were that many different staff
A senior health promotion specialist working with groups had a key role, including human resources, health
Westshire Trust convenes a working group to develop a promotion, general management and the training
policy, which includes representatives of human resources department. This is changed so that responsibility for
officers, general management, consultant psychiatrists, implementation rests entirely with the trust Director of
trade unions and the local voluntary organisation on Human Resources. The alcohol policy is finally approved
alcohol. formally by the trust board.
The working group meets four times, and produces a In the meantime, the trust has been engaged in a major
draft policy. The policy specifies that the trust sees strategic review that has affected many of its services,
sensible drinking as everyone’s responsibility and that all and there follows a long period of substantial
employees will receive basic information about sensible organisational change. Two years after the alcohol policy
drinking. It also covers the trust’s responsibility to develop was approved, it had still not been implemented. There
an environment conducive to self-referral by anyone with had been no education of the workforce about sensible
an alcohol problem, early identification of alcohol-related drinking and no change in the way alcohol was served
problems and the provision of expert confidential help. and sold on trust premises.
It looks at the provision of alcohol on trust premises, and Looking at the stages for developing and
specifies that nonalcoholic drinks should be provided as implementing a workplace policy in the section above,
an alternative at all social functions where alcohol is and the section on the politics of influence, consider these
served, and that alcohol consumption should be questions:
discouraged at nonsocial functions. ■ What steps were taken that facilitated policy
This draft policy goes to the trust board. It receives a development?
lukewarm reception, and there is much concern that it ■ What else could have been done?
will interfere with personnel policies on dealing with ■ Why did the policy receive such a lukewarm
people who drink on duty. There is also discussion and reception by the trust board? Could anything have
disagreement about what constitutes a social and a been done to prevent this?
nonsocial function, and resistance to the idea of curtailing ■ Why was the policy never implemented? Could
social drinking, such as selling alcohol at the employees’ anything have been done to ensure that the
bar and serving it at working lunches, publicity events implementation stage actually happened?
such as the opening of new clinics and leaving parties. ■ Are there any other significant points to note about
Nevertheless, it is passed for consultation, and comes the lessons learnt from this example?
back to the board for final approval. The board members
● Identifies the committee, department or senior crucial in persuading the workforce to look posi-
person who has overall responsibility for taking tively on the new policy.
the policy forward. It is also important that an identified senior
● Identifies key personnel to consult with and member of staff or manager, with political influ-
convince of the need for a policy. ence, acts as a champion for the policy. This person
● Establishes a timescale for policy development. will be crucial in getting the commitment of other
● Prepares a draft policy and consults widely. managers to the policy.
● Prepares the final draft policy for approval.
2. Implementation of the policy
In the case of a workplace policy, it is important to
involve trade unions. This can be achieved either This starts with planning, which will include:
by including trade union representatives on the ● Setting aims and objectives.
working group or by setting up an effective frame- ● Setting up a system for monitoring and
work for consultation and negotiation. This may be evaluation.
● Identifying resources and defining key ● Securing the commitment of management (such
implementation tasks. as elected members, chief officers and senior
● Defining the role of key personnel. management in the case of a local authority).
● Developing an action plan. ● Obtaining the commitment of the whole
workforce or group at which the policy is
Key personnel should be encouraged to participate aimed (such as the prison population or the
actively in identifying their roles and in discussing staff of a business).
boundaries and overlap in roles, so that the poten- ● Providing those responsible for implementing
tial for conflict and confusion is reduced. For the policy with the necessary skills.
example, managers have the primary responsibility ● Overcoming prejudices, discrimination and
for ensuring that their staff are fully conversant stereotyping where relevant (for example, in
with workplace policies and understand what is policies on alcohol and HIV/AIDS).
expected of them. Nevertheless, the trade unions
● Encouraging and assisting the workforce, or the
also have a role in informing the workforce of the
particular groups of people the policy is
policy. These sources of information hopefully will
concerned with, to make choices and individual
be complementary and spell out the same, not con-
lifestyle changes.
tradictory, messages. The open discussion of these
issues will help to increase commitment to making
the policy work. 4. Evaluation
Any policy that is not the subject of regular This should include evaluation of both process and
review risks becoming obsolete. So the working outcomes. It will require the collection of informa-
group must reconvene at intervals to consider tion, both baseline and ongoing.
issues such as the following:
See Chapter 5, section on planning evaluation methods
● Does the workforce know about and for further suggestions.
understand the policy?
● Have attitudes changed to the health issue
covered by the policy? If so, how? How do staff
Campaigning
feel about the policy?
You, or clients with whom you work, may feel
● Has the behaviour of individual staff changed?
strongly about changing policy or practice about a
Does this include changes in working practices health issue, and decide that the way forward is to
and/or individual lifestyles? mount a campaign.
● Are staff getting the help they need? Policy campaigns can range from short-lived
● Are managers and trade unions supporting the local campaigns with the objective of making a
policy? single change to long-term national campaigns.
● Are indicators showing that the policy is Examples of a national pressure group campaign-
making progress towards the attainment of its ing for policy change is Action on Smoking and
aims and objectives? For example, in the case of Health (ASH), which is a campaigning public health
a workplace policy, have absenteeism and charity that works to eliminate the harm caused by
sickness reduced? Or have accident rates tobacco. ASH has a list of policy issues on their
decreased? Has work performance improved? website http://www.ash.org.uk, which includes
Is morale better? inequalities in health.
● How can we improve the effectiveness of the Some pressure groups (such as Shelter) may
policy? provide direct services as well as acting as a pres-
sure group.
3. Education and training
Principles of Campaigning for
This is a continuous process, not a one-off event.
Policy Change
Wherever possible it should be integrated into
existing provision for professional and managerial Some important principles to keep in mind if you
staff development. The purposes of education and are setting up a policy campaign (originally adapted
training include the following: from Wilson 1984) are:
● Be persistent: success requires persistent effort, ● Identify your resources (do you need to
so you must be committed and prepared to put fundraise?).
in a lot of time and energy over a long period. ● Clarify how you will know if your aim is
● Be professional: give care and attention to achieved (set milestones and specific
details (such as well-written campaign outcomes?).
materials with the name of the campaign ● Set an action plan of who is going to do what
clearly evident), and ensure that activities such and when.
as keeping records are undertaken properly.
● Keep a sense of perspective: your campaign may
be vitally important to you, but being perceived PRACTICE POINTS
as fanatical will do your cause no good. ■ Recognise that you and all health promoters have a
● Reflect your ideals: it is no good, for example, role in influencing policy at national, local and at
campaigning for changes to equal opportunities the organizational level.
policy if your own organisation does not have ■ Influencing policy requires careful planning and
good access for people with disabilities. timing. You need to know how national and local
● Be positive: Shelter is called the National health promotion policy is created, developed and
Campaign for the Homeless, not the Campaign changed, and how you can have a voice by
against Bad Housing. commenting on proposals and plans.
● Join with others: rival pressure groups ■ Know the rights and standards you can expect from
campaigning on similar (or even identical) NHS services, and comment on those which you and
issues waste a lot of time, effort and other your clients receive.
resources. If someone is already campaigning ■ Challenge health damaging policy by working with
on your issue, join them rather than setting up others, using your vote and by collective action.
a rival organisation. Or if there is more than ■ Identify how you could be more effective in
one organisation working on similar issues, influencing policy through reviewing your skills in
form a coalition. planning, networking, negotiating and joint
● Involve as many people as possible: this not
working.
■ Start policy change by identifying key stakeholders
only harnesses support but also informs people
about what is wrong and what needs to change. and looking at issues from each of their viewpoints;
use techniques such as force field analysis to
establish how to move forward.
Planning a Policy Campaign ■ When campaigning on health issues, pay attention
to careful planning and be persistent, professional
When you plan a policy campaign, it helps to go
and positive; involve as many other people as
through the same planning process as you would
possible.
with any other kind of health promotion activity.
■ Keep the ethical aspects of activities in mind
See also Chapter 5 for help with planning that applies when campaigning, lobbying and working
to planning a campaign. towards changing health policy and practice;
work with other people to build up trust and mutual
● Identify your aims clearly.
respect.
● Decide the best way of achieving them (public
meetings? press coverage? lobbying MPs and
local councillors? a petition?).
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235
Glossary
This glossary contains explanations of terms and Community development: Working with people to
abbreviations used in this book, and in health pro- identify their concerns, and support them in col-
motion and public health generally. Refer to the lective action for the good of the community as
Index to find where the terms are used and also a whole.
explained in more detail in the text. Community health project: A programme of work
Words in italics appear in this list as separate organised by an agency or a local organisation
entries. with the aim of improving health by some com-
bination of community activity, self-help, com-
Advocacy: Representing the interests of people who munity action and/or community development.
cannot speak up for themselves because of Community health services/community services:
illness, disability or other disadvantage. Health services provided in people’s homes or
Agenda 21: A worldwide movement to address from premises in the community such as GP sur-
environmental concerns for the 21st century, geries, health centres, clinics and small commu-
focusing on sustainable development. nity hospitals (as distinct from services provided
Aim: Broad statement of what you are trying to in major hospitals).
achieve (e.g. in a health programme or activity). Community health work: This is community work
Audit: Systematic examination of a service in order with a focus on health concerns, but generally
to check and improve its quality. health is defined broadly to include social and
Care trust: NHS organisation that provides health economic aspects, so that community health
and social care services, formed by the merger of work may encompass almost as broad a range of
local authority social care services with NHS activities as community work that does not have
primary and community health services. a specific health remit.
Commissioning: In the context of commissioning Community strategy: Local plan led by local
health services, this means deciding what health authorities with the aim of improving economic,
services and programmes are needed to improve social and environmental wellbeing.
the health status of the local population and Community work: Working with community
ensuring that they are provided. groups and organisations to overcome the com-
Communicable disease: Diseases that can be trans- munity’s problems and improve people’s quality
mitted from one person to another; often called of life. Community work aims to enhance the
infectious or contagious diseases. sense of solidarity and competence in the
Community action: Activity carried out by people community.
under their own control in order to improve their Comparative need: Comparison between similar
collective conditions. It may involve campaign- groups of people, some in receipt of something
ing, negotiating with or challenging authorities such as a service and some not. Those who are
and those with power. not are then defined as being in comparative
236 Glossary
need. (See also expressed need, felt need and norma- sound research that shows they are likely to be
tive need.) successful in achieving their aims.
Competencies: The combination of knowledge, Expressed need: What people say they need;
attitudes and skills needed to do a particular job. expressed requests or demands. (See also com-
Coronary heart disease (CHD): Heart disease parative need, felt need and normative need.)
caused by poor circulation of blood to the heart Facilitation/facilitator: The process of making/a
muscle because the blood vessels have become person who makes something more easily
blocked. This may show up as a heart attack or achieved. For example, a group facilitator will
chest pain (angina). help a group of people to get to know each other
Cost–benefit analysis: The process of comparing and discuss things together, but will not be the
the benefits with the costs (e.g. of a health pro- dominant leader.
gramme or activity). Felt need: Need that people feel; what they want.
Cost-effectiveness analysis: Comparing the costs This is not necessarily what they say they need.
and outcomes of alternative activities to achieve (See also comparative need, expressed need and nor-
the same goal (e.g. comparing the cost of a tele- mative need.)
phone helpline with nicotine replacement Green Paper: A government policy document
therapy to achieve the goal of successfully issued for consultation. Becomes a White Paper
helping people to stop smoking). when it is finalised and formally agreed as gov-
Cross-sectoral: Working across the boundaries of ernment policy.
different sectors, e.g. health services working Health 21: A policy framework published by the
together with businesses and voluntary organi- World Health Organization in 1999, which set out
sations. Sometimes also called intersectoral. 21 targets for the European region in the 21st
Demography: The study of the statistics about a century.
population, such as birth, death and age profile. Health action zone: Area of high health need
Educational objectives: What an educator would selected by government for special funding and
like clients to know, feel and do as a result of the health programmes.
education. Health and social care services: A wide range of
Effectiveness: The extent to which a programme, services to meet people’s health and social needs.
activity, service or treatment achieves the result Health care tends to mean services provided by
it aimed for (e.g. the effectiveness of a health the NHS, and social care usually refers to serv-
promotion programme would mean the extent to ices provided by local authorities, especially
which it had achieved objectives such a specified social services departments. In many instances
positive change in the population’s health). services are provided by both. They may also be
Efficiency: A term applied to a programme or activ- provided by the voluntary sector.
ity to denote how good the process (as distinct Health authority: The statutory NHS organisation
from the outcome) is in terms of, for example, responsible for health services for a defined pop-
value for money or use of time; it is about how ulation until abolished in 2002, when its respon-
results are achieved compared with other ways sibilities were largely taken on (in England) by
of achieving them. primary care trusts and care trusts.
Epidemiology: The study of the distribution, deter- Health education: Planned opportunities for people
minants and control of disease in populations. to learn about health, and to undertake volun-
Ethnicity: Racial origin or cultural background. tary changes in their behaviour.
Ethnic minority: Group differentiated from the Health For All: A movement started in the 1980s
main population of a community by racial origin by the World Health Organization. It included
or cultural background. health targets and stressed basic principles of pro-
Evaluation: The process of assessing what has been moting positive health through health promo-
achieved (the outcome) and how it has been tion and disease prevention; reducing inequalities
achieved (the process). in health; community participation; cooperation
Evidence-based practice: Based on reliable evi- between health authorities, local authorities and
dence that something works. For example, evi- others with an impact on health; and a focus on
dence-based health promotion means health primary care as the main basis of the healthcare
promotion projects or programmes based on system.
Glossary 237
Health gain: A measurable improvement in health programme to encourage women to attend for a
status, in an individual or a population, attribut- breast cancer screening test (mammogram)
able to earlier intervention. might be assessed in terms of how many women
Health gap: The difference between the overall attended; the long-term outcome could be a
health of the more wealthy and more deprived change in the rate of women who died of breast
communities in a population. cancer.
Health impact assessment (HIA): Systematic Incidence: The number of new episodes of illness
process of estimating the effects of a specified arising in a population over a specified period of
action – a programme, policy or project – on the time.
health of a defined population. For example, Inequalities in health: The gap between the health
what difference a new transport policy would of different population groups, such as better-off
have on the health of the population affected by and more deprived communities, or people with
it. different ethnic backgrounds.
Health promotion: The process of enabling people Input: The resources that go into a programme or
to increase control over, and to improve, their activity, including money, time, staff and
health. materials.
Health-related behaviour: Things people habitu- Lifestyle: The particular way of life of a person
ally do in their daily life that affect their health. or group, often referring to health-related behav-
Usually refers to issues such as whether they iour such as smoking, drinking, diet and
smoke, whether they take exercise, what they exercise.
eat, their sexual behaviour, how much alcohol Local strategic partnership (LSP): Local NHS, local
they drink, drug use. Sometimes simply called authority and other agencies working together to
‘health behaviour’. develop and implement local strategy for neigh-
Health target: A quantified, measurable improve- bourhood renewal.
ment in health status, by a given date, which Low birthweight: The weight of a baby at birth of
achieves a health objective. It provides a yard- less than 2500 grams. High rates of low birth-
stick against which progress can be monitored. weight babies in a population indicate poor
Healthy Cities: A World Health Organization initia- health overall.
tive started in 1987 to improve health in urban Monitoring: The process of regularly reviewing
areas. Involves collaborative work between local achievements and progress towards goals.
government, health services, local businesses, Morbidity/morbidity rate: Illness/incidence of
community organisations and citizens. The illness in a population in a given period.
Health for All (UK) Network is the coordinating Mortality/mortality rate: Death/incidence of death
body for action on Healthy Cities within the UK. in a population in a given period.
Healthy living centres: Centres or networks of Multidisciplinary: Involving people from different
activity that aim to promote good health, devel- professions (disciplines) and backgrounds.
oped by partnerships with local participation. National Healthy Schools Standard (NHSS): Gov-
Funded from the National Lottery. ernment standard introduced in 1998 as a joint
Healthy Universities: World Health Organization ini- venture between the Department for Education
tiative to promote health in university settings. and Skills and the Department of Health. Aims
High-risk approach: Public health approach that to develop health promoting schools through
prioritises people particularly at risk of ill health. programmes of social, personal and health edu-
(Compare with whole-population approach.) cation for the pupils, the way the school is run;
Holistic: In the health context (as in ‘holistic and the health and wellbeing of staff, parents
approach to health’) this means taking into and the wider community who have contact
account all aspects of a person – physical, mental, with the school.
emotional, social – as well as their social, eco- National Institute for Health and Clinical Excel-
nomic and physical environment. (As distinct lence (NICE): National body that provides
from an approach which focuses only on, for patients, health professionals and the public with
example, the physical functioning of the body.) authoritative, robust and reliable guidance on
Impact: A term sometimes used to describe short- best practice in relation to public health drugs,
term outcomes. For example, the impact of a treatments and services across the NHS.
238 Glossary
National occupational standards: Nationally Opportunity costs: Potential benefits, which will
agreed statements of best practice about what not be realised if one thing is done instead of
people are expected to do in their jobs. another. For example, if there is only enough
National service framework (NSF): National docu- time and money for one health programme (A or
ment that sets out the pattern and level of service B), and it is spent on A, the opportunity costs are
(standards) which should be provided for a the potential benefits of spending on B that will
major care area or disease group, such as mental be forgone.
health or heart disease. Ottawa charter: A document launched in 1986 at an
National strategies for health: Government stra international World Health Organization confer-
tegies to improve the health of national ence in Ottawa, Canada, which identified key
populations. themes for health promotion practice.
Neighbourhood renewal strategy: Strategy devel- Outcome: The end product of a health programme
oped by local agencies with a coordinated or activity, expressed in whatever terms are
approach to tackle the social and economic con- appropriate (e.g. changes in people’s attitudes or
ditions in the most deprived local authority knowledge, changes in health policy, changes in
areas. the uptake of services or changes in the rate of
Network: A group of people who exchange infor- illness).
mation, contacts and experience for mutual Patient advice and liaison services (PALS): Estab-
benefit. lished from April 2002 within NHS trusts to help
New Deal for Communities: Government funding patients, families and carers to resolve problems
for deprived communities to support plans that or air concerns. Replaced Community health
bring together local people, community and vol- councils.
untary organisations, public agencies and local Performance management: Systematic manage-
businesses in an attempt to make improvements ment practices and monitoring systems, which
in health, employment, education and the physi- support people so that they can achieve their
cal environment. work objectives.
New public health: An approach to public health Policy: A broad statement of the principles of how
that emerged in the 1980s. It shifted emphasis to proceed in relation to a specific issue, such as
from a lifestyle approach focused on people’s a national policy on transport, a local authority
individual health behaviour to a new focus on policy on housing or a policy on how to deal
political and social action to address underlying with alcohol issues in a workplace.
issues that affect health (such as poverty, employ- Premature death: Death under 65 years of age.
ment, discrimination and the environment High rates of premature death in a population
people live in). indicate poor health overall.
NHS Direct: A national NHS telephone helpline Prevalence: Measure of how much illness there is
staffed by specially trained nurses. in a population at a particular point in time or
NHS trust: An independent body within the over a specified period.
NHS that provides health services in hospitals. Primary care: Services that are people’s first point
Some NHS trusts provide specialised services, of contact with the NHS, such as services pro-
such as ambulance services or mental health vided by GPs, practice nurses, district nurses and
services. health visitors. (As distinct from secondary care,
Nongovernmental organisation (NGO): Organisa- provided in hospitals.)
tion that is independent of government control. Primary care trust (PCT): An NHS body whose
Normative need: Need defined by an expert or pro- main tasks are to assess local health needs,
fessional according to that person’s or profes- develop and provide primary care services and
sion’s standards. (See also comparative need, felt commission secondary care services from hospi-
need and expressed need.) tals and specialised services run by NHS trusts.
Objective: Applied to a health programme or activ- PCTs are run by a board whose members include
ity, this means the desired end state (or result, or GPs, nurses, representatives from local authority
outcome) to be achieved within a specified time social services and the lay public.
period. Objectives are usually more specific and Primary healthcare team: Health workers, usually
detailed than aims. based at a GP surgery or health centre, who
Glossary 239
provide community health services. They include ment, and (ultimately) the decrease in rates of
GPs, district nurses, practice nurses and health illness and death from breast cancer (compare
visitors. with qualitative).
Primary health education: Health education directed Resources: A term often used in health education
at healthy people, aiming to prevent ill health and health promotion to mean educational and/
arising in the first place. or publicity materials such as leaflets, posters,
Primary prevention: Stopping ill health arising displays and videos.
in the first place. For example, eating a healthy Risk factor: An attribute, such as a habit (e.g.
diet, not smoking and taking enough exercise smoking) or exposure to an environmental
are factors in the primary prevention of heart hazard, that increases the likelihood of develop-
disease. ing an illness.
Private sector: A collective term for business and Saving Lives: Our Healthier Nation: National strat-
commercial organisations. (See also sector.) egy for health in England, published in 1999,
Process: All the implementation stages of a health which sets out priority areas (cancer, heart
programme or activity that happen between disease and stroke, accidents, mental health) and
input and outcome. sets national targets.
Project: A one-off, time-limited programme of work Screening: The application of a special test for
with clearly identified start and finish times, everyone at risk of a particular disease to detect
aims and objectives. whether the disease is present at an early stage.
Public health: Preventing disease, prolonging life It is used for diseases where early detection
and promoting health through work focused on makes treatment more successful.
the population as a whole. Secondary care: Specialised healthcare services
Public sector: A collective term for organisations provided by hospital inpatient and outpatient
that are controlled by the state and publicly services.
funded, such as the NHS, local authorities, Secondary health education: Health education
police, fire, probation and prison services. Often directed at people who are already ill, to prevent
also called statutory sector/services because ill health moving to a chronic or irreversible
they are governed by laws (statutes). (See also stage, and to restore people to their former state
sector.) of health. Often involves educating patients
Qualitative: Concerned with quality – how good or about their condition and what to do about it.
bad something is according to specified criteria, Secondary prevention: Intervention during the
usually expressed as a description in words early stages of a disease to prevent further
rather than numbers. For example, qualitative damage.
data about the outcome of a breast screening pro- Sector: Organisations are often categorised into
gramme could include users’ descriptions of three types: public sector (such as the NHS and
how they felt about it: whether they found it local authorities), private sector (business and
painful, embarrassing, well-organised, etc. commerce) and voluntary sector (charities, not-
(compare with quantitative). for-profit and voluntary organisations).
Quality: How good something (such as health Self-empowerment: Ability to have control over
service) is when judged against a number of your own life.
criteria. Self-esteem: How good you feel about yourself;
Quality Protects: Services for children in need, your opinion of yourself.
including vulnerable children in local authority Social capital: Investment in the social fabric of
care. society, so that communities have characteristics
Quality standard: An agreed level of performance such as high levels of trust and supportive net-
negotiated within available resources. works for the exchange of information, ideas and
Quantitative: Concerned with measurable quan- practical help.
tity, usually expressed in numbers. For example, Social inclusion/exclusion: A sense of belonging
quantitative data about the outcome of a breast to/feeling alienated from the community in
screening programme could include the percent- which a person lives.
age of the women invited who actually attended, Social marketing: The systematic application of
the percentage called back for further assess marketing, along with other concepts and
240 Glossary
techniques, to achieve specific behavioral goals cations (e.g. in rehabilitation programmes fol-
for a social good. lowing a stroke).
Stages of change: A cycle of stages a person usually Victim-blaming: Blaming people for their own ill
goes through when changing a health-related health when it is rooted in their social and/or
behaviour, such as stopping smoking. Stages are: economic circumstances. For example, blaming
(1) not yet thinking about it; (2) thinking about people for contracting lung cancer (‘it’s their
changing; (3) being ready to change; (4) action own fault’) because they smoke, but ignoring the
– making changes; (5) maintaining change; then reasons for smoking – which could include lack
either maintaining the changed behaviour per- of education, no support available to stop
manently or (6) relapsing – often then repeating smoking, or smoking used as a way of coping
the cycle by thinking about changing again (2). with stresses such as poverty, poor housing,
Statutory organisations/agencies: Public sector single parenthood or unemployment.
organisations or agencies such as local authori- Voluntary organisations: Not-for-profit organisa-
ties and NHS organisations. tions, ranging from large national ones to small
Statutory sector: Another term for the public sector. groups of local people, run by volunteers but
Strategy: A broad plan of action that specifies what possibly employing paid staff. Small local volun-
is to be achieved, how and by when; it provides tary organisations are often called community
a framework for more detailed planning. groups.
Sure Start: Government schemes in areas of high Voluntary sector: A collective term for voluntary
health need, which aim to support parents and organisations, community groups and charities.
children under 4 years. (See also sector.)
Sustainable development: Development that meets Walk-in centre: NHS service offering advice, infor-
the needs of the present without damaging the mation and treatment for health problems from
health or environment of future generations. specially trained nurses, with no appointment
Target group: The people who are intended to necessary.
benefit from a public health or health promotion White Paper: Government policy, often accompa-
activity. nied by legislation. Usually follows a Green Paper.
Targets: Quantified and measurable achievements Whole-population approach: Public health
to aim for, by specified dates, which provide approach that focuses on a whole community
yardsticks against which progress can be moni- rather than on individuals who are identified as
tored. (See also health target.) being in particular need. (Compare with high-risk
Tertiary health education: Health education approach.)
directed at people whose ill health has not been, World Health Organization (WHO): An intergov-
or could not be, prevented and who cannot be ernmental organisation within the United
completely cured. Concerned with educating Nations system whose purpose is to help all
about how to make the most of the remaining people attain the highest possible level of health
potential for healthy living, and how to avoid through public health programmes. Its head-
unnecessary hardships, restrictions and compli- quarters are in Geneva, Switzerland.
241
Index
accepting people, 134 agencies see organisations and assertiveness, 135

accident prevention, 92f agencies assessment see evaluation
accountability to community, 217 agenda(s) Association of Public Health
achievement, monitoring see in community development, 213 Observatories, 54
monitoring hidden, 183 attention (yours when listing to
action, 74–75 agenda 21 (UN), 225, 235 clients)
to change policy, timing, 227 agreement in overcoming resistance giving, 137, 139
community, definition, 209, 235 to change, 117 wandering or insufficient, 137,
social, group enabling, 178 aims (of health promotion), 32–36 141
as stage in transtheoretical model, analysing, 34–36 attitudes
194 definition and distinction from changes in, 196–198
see also health action zones objectives, 66, 235 assessing, 72
(HAZs) educational see education to health promoter, negative,
Action on Smoking and Health identifying and clarifying, 32–34, 140–141
(ASH), 232 37b, 63 of health promoter influencing
action plans, 63 client groups, 183 behavioural change
community health project, 217 information and its outcome, 202
helping client with development, appropriateness to, 148–149 audience segmentation, 23
192, 199 mass media and, 154 audit, 102–103, 235
setting, 74 for meeting needs, 84 and research and evaluation, 103
action research, 97–98 methods of achieving, 67–69 authoritarian leadership style, 180
active listening, 136–137 community health project, 216 autonomy
activities range of, 68–69 dependency vs, 134
community-based, 208 reviewing, community health respect for, 40–41
economic, 24 project, 217 awareness/self-awareness (health)
health education, 165–166, 166t setting, 65–67, 68b assessing changes in, 72
physical see physical activity community health project, 216 eating and, 70f
regulatory, 24 see also objectives; targets groups for raising of, 178
structured, 197–198 alcohol consumption strategies for increasing, 192–193
adherence (compliance) vs informed excessive, 69, 128
choice, 33–34 changing behaviour, 203b Bangkok Charter for Health in a
adolescent smoking, 32–33 in workplace, 231b Globalized World, 12
advertising in client information, 149 allies, making, 227 bargaining, 123
advocacy (by promoter), 12, 235 alternative medicine practitioners see Be WELL Community Health
for behavioural change, 201–202 complementary medicine Project, 213b
in lifestyle, 32 practitioners Beacon scheme, 55
community work, 211 appearance, physical, 143 behaviour (general)
International Union for Health appendices in written report, 109 in client groups, 182–183
Promotion and Education ASH (Action on Smoking and difficult, 189–190
on, 48 Health), 232 committee, 125–126
242 Index
of health promoter influencing equation, 114–115 to successful partnership

behavioural change implementing, 114 working, 123
outcome, 202 key factors for success, 114–115 committees
behaviour (health-related), 22, 237 management, 114–117 community health project, 217
change in, 32–34, 35t, 191–205 in policy see policy effective work, 125–126
assessing/evaluating, 72–73, resistance communicable disease, 82b, 235
200–201 overcoming/dealing with, communication
continuum of values and, 197 116–117, 195 with clients, 25, 133–161
decision-making see reasons for, 116 barriers, 140–141
decision-making social see social change non-verbal, 141–144
healthy eating and, 70f Change for Life, 200 in overcoming resistance to
models, 192–195 charts, 148t, 150–151 change, 116–117
motivation for, 195 Chief Medical Officer, 12–13 in patient education, 173, 174b
self-empowerment and see children tools, 147–161
self-empowerment improving health, 12, 96 with colleagues, 122
stages of, 193–195, 240 perceptions of health, 5 community (communities), 53,
strategies see strategies self-esteem, 136 207–221
goals and targets, 23, 66 see also parents action in, definition, 209, 235
individual’s, as cause of ill health, choices/options definition, 208
32 help with identifying and making development, 209, 211–214
see also lifestyle; sexual behaviour or choosing, 192b, 199 definition, 209, 235
beliefs informed, vs compliance, 33–34 health workers see health
of change not being of benefit, making them easy choices, 202 workers
116 churches, 50 health projects, 214–219
factors shaping, 9b Citizen’s Council, 225 definition, 209, 235
irrational, 198 client(s) health work (in general)
quiz, 198b communication with see definition, 208–209, 235
beneficence, 40 communication kinds of activities, 208
benefits and rewards definition, 78 principles, 209–210
behavioural change, 200–201 education see education individual freedom vs health of,
client group work, 178 feedback from see feedback 39–40
see also cost–benefit analysis in groups see groups participation see participation
biased questions, 138 involvement see involvement people-centred health promotion
birthweight, low, 237 people who influence, 70 and, 80
Black Report, 10 relationships with see services (incl. health services),
boards (display), 148t, 150–151 relationships 209, 235
body contact, 142–144 see also consumers; people; users work (in general), 207–221
body language (non-verbal client-centred approach, 35 competency, 219–220
communication), 141–144 climate for behavioural change, definition, 208
booklets, 150–151 creating, 199 evaluation see evaluation
bottom up vs top down approach, closed questions, 138 key terms, 208–209
36–38 Cochrane Centre and Collaboration, planning see planning
brainstorming, 187 150–151 strategies, 91, 235
buzz groups, 187 code of practice, 41–42 working with the, 23, 207–221,
collaborative and joint working 235
Calderdale local health strategy, 56b (working with others), 27, community groups, 57, 208, 211
campaigning, 232–233 88, 121–130 community nurses, 55, 209
cancer, 92f through creating teams, 124 comparative need, 79, 235–236
skin, prevention, 163 see also partnership competencies, 25–26, 131
care trust, 235 collective power, 226 in community work, 219–220
primary, 50–51, 53, 224, 238 colour in display materials, 150 competition, 23
categorising, 196 commercial companies and complementary/alternative medicine
CDs, 148t organisations, 33, 49–50 practitioners, 55
centrality of community, 209–210 advertising in client information, in community, 213b
chair, committee, 125 149 compliance vs informed choice,
change(s), 114–117 commissioning, 235 33–34
assessing, 72–73 commitment conclusions
behavioural see behaviour as stage in transtheoretical model, of formal talk, 172
in community, charting, 218b 194 of written report, 109
Index 243
confidence see self-confidence decision-making see also health trainers;

conflict on change information and advice;
in committees, 126 strategies, 198–199 learning; local education
of evaluation in community on what to change, 196 authority; teaching; training
work/projects, 214, 216–217 ethical, 40–41 effectiveness
of loyalty, 202 demands, 78 of information systems, 108
resolution style, 126b supply and, 79 mass media used to achieve,
confronting a client group member, demography, 236 153–154
189 Department of Health meaning, 107, 236
consultation in community health refocused in 2002, 51 personal, skills, 107–120
project, 217 Web site, 159–160 in priority-setting, 88
before setting up, 215 dependency vs autonomy, 134 of strategies for behavioural
consumer (in NHS policy), voice of, diaries change, 194
225–226 smoking, 200b in time use see time management
see also users time, 110–111 of working with others, 121–130
consumer groups, 87 dietary energy restriction, 154b see also cost–effectiveness
contact disability services see services efficiency, 236
bodily, 142–144 disasters in a group, 188 as quality criterion, 117b
eye, 143–144 discussion (between members) elitist networks, 228
contemplation stage (transtheoretical in client groups, 186–188 emotional health, 6
model), 194 display materials, 148t, 150–151 see also feelings
contents of written reports dissatisfaction leading to change, employers, 57, 92f
list of, 109 114–115 empowerment, 33
research report, 101 distractions in a group, 188 encouraging people to talk, 137–
contingency planning in formal talk, drop-in, 198b 139
172–173 duties, questions about, 40 energy restriction, dietary, 154b
contracts, learning, 167–168, 168b DVDs, 148t England, improving health, 12
contradictory messages, 141 national strategies, 93
convenience sampling, 100 eating, healthy, 69, 70f English (language)
cooperating, 128 economic activities, 24 limited, 141, 142b
coordination, 122–124 economic regeneration, 48–56 plain, in display materials, 150,
appointing a coordinator, 122– economics (health), research and, 151b
123 101–102 enjoyment and health, 197b
coping strategies in behavioural see also cost environment (physical)
change, 201 editor (local press), writing letter to, assessing changes in, 73
coronary heart disease (CHD), 85, 158–159 as quality criterion, 117b
225, 236 education (health), 18–19, 34, 35t, environmental health measures, 24
cost(s) (economic), 101 163–175 environmental health officers/
opportunity, 101–102, 238 1° (primary), 22, 239 practitioners, 56
see also value for money 2° (secondary), 22, 239 epidemiology, 236
cost(s) (not specifically economic) 3° (tertiary), 22, 240 data, 81–82
of behavioural change, 200 4° (quaternary), 22 equity, 46
in evidence-based research, 101 aims/goals/objectives in, 65, see also inequalities
cost–benefit analysis, 102, 236 236 ethical issues
cost–effectiveness analysis, 102, 236 of maximum involvement, decision-making, 40–41
counselling, 199 165 dilemmas, 36–40
in community, 213b realistic, indentifying, in management, 28, 108
group, 178 167 priority setting and, 88
on health choice, 192b setting, 66–67 ethnic minority, 236
cross-sectoral, 236 competence in, 25 communication problems,
cultural gaps, 140–141 definition, 18–19, 236 140–141
customers see client; users formal talks, 170–173 ethnicity, 236
groups in, 178 European Community, 46
data see information and data talking to, 163 European Network for Workplace
deal-making see negotiation national strategies, 92f Health Promotion, 228
death see mortality overcoming resistance to change, European Network of Health
decentralised planning in 116–117 Promoting Schools, 230
community health patient, improving, 173–174 European Public Health Alliance
promotion, 211 programmes, 22 (EPHA), 48
244 Index
evaluation (assessment; making from users/clients, 73–74, pressure, 49, 228, 232–233
judgments) 139–140 steering, community health
and audit and research, 103 on educational session, 169 project, 217
of behavioural change, 200–201 feelings and emotions, clients, 135 target, 240
of client group, 185 in groups, 178
of community work, 211, 215f sharing initial feeling, 186 hand movements, 143
conflicts, 214, 216–217 negative see negative feelings handouts, 148t
planning, 216–217 reflecting, 138 head movements, 143
competence in, 25–26 felt need, 78, 236 health, 3–15
flowchart for planning and, 64f fire fighters, 57 awareness of see awareness
health impact (HIA), 103–104, flip-charts, 148t behaviour relating to see
237 force field analysis, 227 behaviour
of learning see learning forming (in groups), 182 beliefs see beliefs
meaning, 71, 236 foundation trusts, trusts, 53–54 concepts of, 4–7, 210
of needs, 83–84 freedom see individuals development, 18
planning methods of, 63 funding, community work, 211, 216 dimensions of, 6–7, 8b
of policy implementation, 232 enjoyment and, 197b
of population’s health and Galway Consensus Statement, 26 factors affecting/determinants of,
well-being, 26 Gantt chart, 112–113, 114b 7–10, 8b
reasons for, 71–72 gaze, direction of, 143–144 gain, 17, 237
who it’s for, 72 gender, 10 improvements, 18
see also monitoring general practice managers (GP attributable, 18
evidence-based practice, 236 practice managers), 55 historical aspects, 10–11
health promotion, 93, 95–96 general practitioners (GP), 54–55 international initiatives, 11–12
on Internet, 159 goals (and goal setting) measurable, 18
exercise see physical activity behavioural, 23 national initiatives, 12–13
exit stage (transtheoretical model), counselling/helping with, 192, in public health see public
194–195 199 health
expectations in groups, sharing educational see education inequalities see inequalities
initial, 186 see also aims; objectives; targets medicine and, 8–10
experiential learning, 196 good practice in group work, 190b needs see needs
experimental research, 97–98 government, 48 objectives in, 65–66
experts Green Paper, 236 status, assessing changes in, 73
need defined by (=normative ground rules in groups, 186 targets, 66
need), 78, 238 group(s), 177–190 health 21, 11, 236
power of, 226 client (in general), 177–190 Health Action Model (HAM),
expressed need, 78, 236 appropriate situations for, 192–193
community’s, 211 178–179 health action zones (HAZs), 91, 236
see also demand behaviour see behaviour health activities, positive, 22
eye contact, 143–144 benefits, 178 health and safety at work, 229
dealing with difficulties, health and social care services, 236
facial expression, 143 188–190 health authorities, 50, 236
facilitation (and facilitator), 236 educational see education local, 50
community health promoters, 209 good practice, 190b health centre, local, change in, 115b
competence, 25 hidden agendas, 183 health economics and research,
group work, 180 joining, 179b 101–102
learning, 164–170 members’ roles, 182–183 health education see education
overcoming resistance to change, people who influence, 70 Health For All, 11, 230, 236
116 as resource, 69–70 health gap, 237
facilities (incl. premises) setting up/planning, 183–185, health impact assessment (HIA),
community health project, 216 189b 103–104, 224, 237
for formal educational talks, 170 starting/getting going, health improvement and
group meeting, location, 183–184 185–186 modernisation plans
as resources, 71 talking to (in education), 163 (HIMPs), 94
feasibility in priority-setting, 88 types, 178 Health in Prisons Project (HIPP), 230
Featherstone High School, healthy community, 57, 208, 211 He@lth Information on the Internet,
living changes, 127b–128b consumer, 87 159
feedback from other people leadership, 180–182 Health of the Nation, 93
from professionals, 73–74 population see populations health programmes see programmes
Index 245
health promoters (HPs), 45–59 homeless peoples’ perceptions of input, 237

advocacy see advocacy health, 5 measuring, 73
community, facilitator role, 209 hospitals, health promotion policies, professional, 69
dissemination of resources to 229–230 Institute of Health Promotion and
other HPs, 159 humanistic psychology, 191 Education (IHPE), 49
ideal, 38 instruction sheets and cards, 150–151
improving your role as, 57 illness services see services international dimensions
negative attitudes to, 140–141 impact, 237 health-improving initiatives,
health promotion, 17–30 health, assessment (HIA), 11–12
activities, framework, 24 103–104, 237 health-promoting agencies, 46–48
agencies see organisations and incidence, 237 occupational standards/
agencies individuals (different people) competencies in health
agents see health promoters behaviour as cause of ill health, promotion, 26
aims see aims 32 International Union for Health
competencies, 25–26, 131 costs of change to, 115 Promotion and Education
defining, 17–19, 237 freedom to choose, 39–40 (IUHPE), 46–48
evidence-based see evidence- lifestyle, 32 Internet and Web sites, 148t, 159–160
based practice `healthy’ (the term) understood community health project, 216
models, 34–36 by, 3–4 intervention
needs see needs interviewing, 99–100 definition, 18
occupational standards see in people-centred health mix, 23
occupational standards promotion, 80 spectrum of possible modes of, 31
philosophical issues, 31–43 industrial organisations, 49–50 interviews
planning see planning inequalities in health, 10, 48, 237 personal, 99–100
priorities see priorities communities-based work and, on TV/radio, 155
scope, 17 210–211 intolerance for change, 116
specialists, 54–55 reducing, 27 introduction
health protection, 19, 25 widening, 38 to formal talk, 171–172, 171b
health target, 237 influencing in written report, 109
health trainers, 55 of behavioural change outcome involvement and representation
Health, Work and Well-being Strategy, by health promoter’s in education, aiming for the
57 attitudes and behaviour, maximum, 165
health workers, local/community 202 lay persons in NHS, 225–226
development, 209 of client group, people who overcoming resistance to change,
threat to, 213–214 influence, 70 116
healthcare services see services of policies, 25–26, 224 in public health, 20
`healthy’, different peoples’ political see political influencing as quality criterion, 117b
understanding of the term, power to influence see power see also participation
3–4 of practice, 25–26 irrational beliefs, 198
Healthy Cities, 230, 237 information and advice (users/ irrelevancy (to clients) of information
Healthy Living Centres (HLCs), 91, clients/patients), 147–149 material, 149
237 community work, 211
Healthy Living in the fact/fad/fashion in, 31 Jakarta Declaration, 12, 18
Neighbourhood, 127b– insensitivity, 33 joint forums (community), 211
128b on Internet, providing, 159–160 joint planning, 123–124
Healthy Scotland health, 53 Patient Advice and Liaison joint working see collaborative and
Healthy Universities, 237 Services (PALS), 54, 238 joint working (working
heart disease, 92f types/uses/advantages/ with others)
in Be WELL Community Health limitations, 148t, 149–150 journal articles, 97
Project, 213b selecting and producing, 147– judgment, making
coronary (CHD), 85, 225, 236 149 about people, 134
height differences between people, statistical, 151 about value of health promotion
143 information and data (you and interventions see evaluation
hidden agendas, 183 professionals) justice, 40
high-risk approach, 237 managing, 108 social, 117b
coronary heart disease, 85 on needs, finding and using,
higher education institutes, 56–57 81–83 key events (in project), 74
holistic (approach to health), 237 informed choice vs compliance, key personnel in implementation of
holistic model of health, 5–6 33–34 policies, 232
246 Index
key points local public health motivation for behavioural change,

in display materials, emphasis, gathering information, 82b 195
150–151 strategies, 94–95 multidisciplinary, meaning of term,
in educational setting, 167 local strategic partnership (LSP), 53, 237
in formal talk, 172 94–95, 224–225, 237 multidisciplinary public health, 19
knowledge logs, time, 110–111 multiple questions, 138–139
assessing changes in, 72 low birthweight, 237 mutual support in groups, 178
education and varying degrees of, loyalty conflicts, 202
165 name games, 185–186
healthy eating, 70f maintenance stage (transtheoretical National Health Service see NHS
see also understanding model), 194 National Health Service and
management Community Care Act
language of change, 114–117 reforms, 50
barriers, 141 competence, 25–26 National Healthy Schools Standard
in display materials, 150 ethical, 28, 108 (NHSS), 237
in newspaper articles, 157 of information, 108 National Institute for Health and
lateral relations, creating, 124 of project work, 111–114 Clinical Excellence (NICE),
lay persons/people of quality, 27, 116–117 53, 237
perceptions of health, 4–5 of resources see resources Citizen’s Council and, 225
representation in NHS, 225–226 of risk, 27 national occupational standards, 19,
leadership skills in, 107–108 238
client groups, 180–182 time see time management National Service Framework (NSF),
strategic, 27–28 manufacturers, 50 85, 238
leaflets, 148t, 150–151 marketing for coronary heart disease, 225
learning (for health) competence in, 25 National Social Marketing Centre, 22
contracts, 167–168, 168b social, 19, 22–23, 239–240 national strategies and policies for
evaluating, 168–170 Marmot Review, 10 health/public health, 12–13,
of outcomes, 169–170 mass media see media 48–56, 92f, 93–94, 228, 238
experiential, 196 meaning (of client’s words), 137 at local level to, 92f, 223
facilitating, 164–170 reflecting, 138 making and influencing, 223
factors helping and hindering, media (mass), 50, 153–159 needs (health), 77–89
164b ethical issues, 39–40 assessing, 83–84
methods, 166t local, 83 community, 214–219
specifying, 167–168 medical model comparative, 79, 235–236
varying, 165 of health, 5–7 concepts of, 78–79
principles, 163–164 of health promotion, 34–36, 35t expressed see demand;
level (height differences between medicine and health, 8–10 expressed need
people), 143 meetings, participation in, 124 felt, 78, 236
lifestyle, 237 see also groups finding and using information on,
changes, 32–34 memory (client’s), limited, 141 81–83
data collection, 82 men, perceptions of health, 5 identifying and exploring, 65,
listening, 136–137, 139b see also gender 79–81, 199
literature see research men’s group, 198b counselling, 192, 199
local agencies (in general), 48–50 mental health, 92f learning, diagnosing with
local area agreements, 225 concept of, 6 learners, 167
local authorities, 12, 55–56, 91, 225 milestone planning, 74 normative, 78, 238
local complementary contributions misunderstanding, 116 putting users’ needs first, 80–81
to national strategies, 92f, modernisation, 46 and supply and demand, 79
224–226 monitoring (of achievement and negative feelings and attitudes
local education authority, 56 progress), 237 (client’s), 135
local health authorities, 50 in behavioural change, 200–201 to health promoters, 140–141
local health centre, change in, 115b students, 170 negotiation and making deals
local health policy, 224 see also self-monitoring with clients, 135
local health workers see health morbidity/morbidity rate, 237 in overcoming resistance to
workers data collection, 81–82 change, 117
local media, 83 mortality (death) and mortality rate, in committees, 123
local press, 156–159 237 for policy change, 228
local professionals in community data collection, 81–82 Neighbourhood Renewal Strategy
work, 214 premature, 238 and Fund, 53, 91, 225, 238
Index 247
networks and networking, 128–129 opinions, polarised/extremes of, one-way process vs, 134–135
to change policy, 227–228 196–197 with other organisations,
community, 211 opportunity costs, 101–102, 238 126–130
competency, 25 opposition to community health see also collaborative and joint
definition, 128, 238 project, 217 working
New Deal for Communities, 91, option see choice patient
238 organisations and agencies, 46 definition, 78
New NHS: Modern, Dependable, 50 development, 23 education, improving, 173–174
new public health movement, 10–11, working with other see joint see also clients; users
238 working; partnership Patient Advice and Liaison Services
newspapers, local, 156–159 orientation (individual’s position), (PALS), 54, 225, 238
Next Stage Review report, 53 143 people (the public)
NHS (National Health Service), Ottawa Charter ( for Health Promotion), client and client groups and the
50–54 6, 11–12, 17–18, 238 influence of, 70
structure, 50–51, 51f outcomes empowerment, 33
walk-in centres, 54, 240 assessing, 72–73 ethical management of, 28
NHS Direct, 54, 238 in community health project, feedback from others see feedback
NHS Next Stage Review, 79 measures checklist, 218b involvement, 48–50
NHS Plan, 50, 56 definition, 238 providing Internet information
NHS trusts, 53–54, 56–57, 238 Healthy Living in the and support to, 159–160
foundation trusts, 53–54 Neighbourhood, 127–128 as resources, 209–210
NICE see National Institute for judgements about, 71 in community health project,
Health and Clinical learning, assessment, 169–170 216
Excellence in research studies, 101 seeking views of, 83
non-governmental organisations short term (=impact), 237 working/collaboration with
(NGOs), 48–49, 238 out-ranking, 123 others
non-maleficence, 40 outreach work, 208 see collaborative and joint
non-participant observation, 100 overweight, presenting population working
non-structured interview, 100 statistics, 152f see also clients; consumers;
non-verbal communication, individuals; lay persons;
141–144 pairs (in client groups) users
normative need, 78, 238 introduction in, 185 people-centred health promotion,
norming (in groups), 182 working in, 196–197 80–81
Northern Ireland paraphrasing, 138–139 perceptions see understanding and
improving health, 12 parents perceptions
national strategies, 93 children’s self-esteem and role of, performance (your)
Public Health Agency for, 53 136 in educational setting,
notes for giving educational talk, young parents group learning assessment, 169
170–171 contract, 168b management, 238
nurses, community, 55, 209 participant performing (in groups), 182
observation, 100 personal effectiveness skills, 107–
obesity, population statistics, 152f satisfaction, as quality criterion, 120
objectives, 238 117b Personal Health Budgets: the Shape of
client groups, 183 participation Things to Come, 79
definition and distinction from community, 210–211 personal interviews, 99–100
aims, 66, 238 definition, 209 personal power of, 226–227
educational see education in meetings, 124 personal social services, 21–22
identifying, 63 in overcoming resistance to personnel in implementation of
setting, 65–67 change, 116 policies, key, 232
community health project, and see also involvement see also professionals
achievement, 216 participative leadership style, philosophical issues in health
see also aims; targets 180–181 promotion, 31–43
observation, 100 partnership photographs in press release, 158
occupational health policy see strategic local, 53, 94–95, 224–225, physical activity levels, improving,
workplace 237 92f
occupational standards, 26–29 working in low-income households, 86b
national, 19, 238 behavioural change and, physical appearance, 143
officers, committee, 125 201–202 physical environment see
open questions, 138, 140 competence in, 25 environment
248 Index
physical health, concept of, 6–7 practice people-centred health promotion

pilot materials, 150–151 code of, 41–42 and, 80–81
planning, 63–76 evidence-based see evidence- seeking views of, 83
to change policy, 224, 227 based practice see also personnel
of client group meeting, 183–185, good, in group work, 190b professional concepts of health, 5–7
189b influencing, 25–26 networks of, and policy change,
in community work, 208, 211, pre-contemplation stage 227–228
215f (transtheoretical model), programmes (health)
community participation in, 194–195 developing, 27
210 premature death, 238 health education, 22
competence, 25–26 premises see facilities requiring partnerships between
of educational talk, 170, 171b presentation organisations, 126
contingency plan, 172–173 in formal talk, working on, progress, monitoring see monitoring
framework, 65–75 172 project (and project work), 111–114
joint, 123–124 of press release, 158 community see community
process, 63 of statistical information, 151 definition, 239
of project work, 111–113 press, local, 156–159 managing, 111–114
polarised (extremes of) opinions, pressure groups, 49, 228, 232–233 protocols, 123
196–197 prevalence, 238 proximity to others, 143
police officers, 57 prevention public health, 239
policies, 223–234 primary, 239 improvements, 19
challenging, 226–228 secondary, 239 historical aspects, 10–11
changes in services, 23 involvement in, 20
assessing, 73 skin cancer, 163 local, gathering information, 82b
campaigning, 232–233 primary care, 238 multidisciplinary, 19
planning, 227 primary care services, 51 policies and strategies, 23–24
strategies to, 227–228 primary care trusts (PCTs), 50–51, national see national strategies
in community health, 210–211 53, 224, 238 as resources, 71
in coordinating work, 123 primary health education, 22, 239 see also people; teams
developing and making, 27, 223, primary healthcare team, 238–239 Public Health Agency for Northern
228–232 primary prevention, 239 Ireland, 53
guidelines, 230–232 priorities public health observatories, 54
implementing, 27, 223, 228–232 in community work, 213–219 public sector (statutory sector)
guidelines, 230–232 reviewing community health organisations, 239
influencing, 25–26, 224 project, 217 seeking views of communities
national see national strategies identifying, 65, 87b that they serve, 83
and policies setting, 84–88, 87b–88b publicising, competence in, 25
public health see public health prison officers, 57 purpose (your), clarifying/defining,
as resource, 71 private sector, 239 66b
themes, 46 proactive, being, 80 in written report, 109
policy, 238 probation officers, 57
political influencing, 227–228 procedures, set, 123 qualitative, meaning of term, 239
in overcoming resistance to process, 239 quality, 116–117
change, 117 assessment, 73–74 criteria, 117
populations (and population groups) in group work, 178 definition, 239
health surveillance and in Healthy Living in the of Internet information, 160
assessment, 26 Neighbourhood, 127 management, 27, 116–117
people-centred health promotion judgements about, 71 standards see standards
and, 80 of planning, 63 Quality Protects, 239
see also whole-population professional(s) (and practitioners) quantifiable quality standards, 118
approach associations representing, 49, 226 quantitative, meaning of term, 239
position power, 226 communication with, 122 quaternary health education, 22
positive feelings (client’s), 135 feedback from, 73–74 question(as)
posters, 148t, 150–151 as health promoters see health asking clients, 138–140
posture, 143 promoters asking clients for, following a
power (to influence), 226–227 input, 69 talk, 172
collective, 226 local, in community work, 214 questionnaires, 99
see also self-empowerment need defined by (=normative quorum, committee, 125
PowerPoint presentation, 148t need), 78, 238 quota sampling, 100
Index 249
racist materials and its avoidance, power in, 226 self-confidence, 135–136
149, 151 producing resources, 147–151 building, 195
radio, 155–156 range/types/users/ self-defeating thinking, 198
random sampling, 94 advantages/limitations of self-efficacy, 195
ranking, 196 resources, 148t, 149–150 self-empowerment, 239
rationing, 79 responsibility/responsibilities, behavioural change and, 195–196
reactive, being, 80 108 self-esteem, 135–136, 239
readability test for written materials, in group leadership, 181–182 behavioural change and, 195
150–151 retailers, 50 self-evaluation, 73
receptiveness in communication, revelations, safe, 187–188 self-interest, 116
limited, 140–141 reviewing self-monitoring, 200
recommendations of written report, aims and priorities of community services (illness/health/healthcare
109 health project, 217 and disability), 51, 236
recreational settings, 92f written report, 109–110 developing, 27
references in written report, 109 revising a written report, 109–110 improving, 19
reflecting back to client, 138–139 rewards see benefits and rewards preventive, 23
regulatory activities, 24 risk factor, 239 as resources, 71
relapse stage (transtheoretical risk management, 27 social, 236
model), 194 role-play, 197 user views on using, 81b
relationships rounds, 187 set procedures, 123
creating/establishing Royal Society for Public Health sex education in schools, 84
in behavioural change, 202 (RSPH), 49 sexist material and its avoidance,
good relationships, 123 149, 151
lateral relations, 124 safe revelations, 187–188 sexual behaviour, risky (and
with mass media, 155 sampling, 100–101 interventions), 33, 64
exploring, 134–135 satisfaction, participant, as quality Shifting the Balance of Power Within
relaxation techniques, 201 criterion, 117b the NHS – Securing Delivery,
relevancy (to clients) Saving Lives: Our Healthier Nation, 56
of education, helping them to see, 239 silence in a group, 188
167 scheduling your work, 111 skills
of information material, 149 school, 230 teaching practical skills for health,
reliability healthy living project, 127b–128b 174–175
of information given to clients, sex education, 84 your
149 skin cancer prevention talk in, patient education, 173, 174b
of research, 99 163 personal effectiveness, 107–
religious organisations, 50 see also National Healthy Schools 120
representation see involvement and Standard skin cancer prevention, 163
representation Schools for Health In Europe, 230 smoking, 35t
reputation, using your, 123 Schools Sports Strategy, 96 adolescent, 32–33
research, 28, 91, 96 Scotland campaigning against, 232
audit and evaluation and, 103 homeless single people, 5 cessation courses/programmes
basic tools, 99–101 improving health, 12, 53 etc., 168, 225
published (literature) national strategies, 93 communicating information
searching, 97–98 screening, 239 in press release, 158b
using, 96–98 TB, 85b statistical information, 152f
value for money, 101–102 seating, group meetings, 184 self-monitoring (diary), 200b
your own secondary care, 51, 239 social action, group enabling, 178
small scale study, 98–101 secondary health education, 22, 239 social capital, 10, 239
written report, 101 secondary prevention, 239 social change, 35–36
resources, 239 secretary, committee, 125 healthy eating and, 70f
community work, 211, 216 sector, 239 social factors
group meeting, 184 private, 239 as communication barriers,
management of (in general), 25 public/statutory see public 140–141
dissemination of resources to sector in lifestyle change, 32–33
other health promoters, voluntary, 240 social health, concept of, 7
159 security arrangements, group social inclusion/exclusion, 239
ethical, 28 meetings, 184 social justice, 117b
identifying and selecting self, ethical management of, 28 social marketing, 19, 22–23, 239–240
resources, 69–71, 147–149 self-awareness see awareness social regeneration, 48–56
250 Index
social services, 56, 236 Internet as means of, 159–160 UK Public Health Association
personal, 21–22 mutual, groups providing, 178 (UKPHA), 49
societal health, 7 Sure Start, 91, 240 UN Agenda 21, 225, 235
socioeconomic data, 82–83 surveillance of population’s health, understanding and perceptions (of
specialists, health promotion, 54–55 26 clients/users/lay persons/
speech, non-verbal aspects, 144 sustainable development, 240 public/different people),
see also talking 139–140, 149
spiritual health, 7 talking of health, 4–5
sponsorship, 153 to educate, 168 limited, 141
sport settings, 92f guidelines for giving formal see also knowledge
see also Schools Sports Strategy talks, 170–173 universities, 91, 92f
stakeholders enabling people to talk, 137–138 Healthy Universities initiative,
identifying, 227 see also speech 237
making them allies, 227 target(s), 65–66, 240 urban settings, 230
stand(s), display, 150–151 for behavioural change, setting, users (incl. customers and
standards 200–201 consumers)
occupational see occupational health, 237 definition, 80–81
standards see also aims; objectives feedback from see feedback
quality target group, 240 needs see needs
definition, 239 teaching practical skills for health, service use and the views of, 81b
developing, 118 174–175 social marketing and, 22–23
statistical information, 151 teams see also clients; consumers; people
statutory sector and organisations see joint working through creating,
public sector 124 validity of research, 99
steering group, community health successful, characteristics, 124 value(s) (your), 35t
project, 217 working in, 122–124 analysing, 34–36
storming (in groups), 182 telephone interview, 100 clarifying, 196–198
strategic leadership, 27–28 television, 155–156 continuum, and behavioural
strategic partnership, local (LSP), 53, terminal illness, 22 change, 197
94–95, 224–225, 237 tertiary health education, 22, 240 identifying, 37b
strategies, 240 think sessions, 187 imposing alien or opposing, 32
behavioural change, 196–201 thinking, self-defeating, 198 information consistent with, 149
coping strategies, 201 time management, 110–111 value for money (research), 101–102
effective use, 201–204 in client communication, poor, victim-blaming, 240
sensitive use, 203–204 141 voluntary sector (incl. voluntary
community, 235 project work, 111 organisations), 49, 240
developing and implementing, timing vote, using your, 226
27 to change policy, 227
national see national strategies of press release, 158 Wales, health improvement and
neighbourhood renewal, 53, 238 Together for Health: a strategic approach promotion, 12, 53, 93–94
public health see public health for the EU 2008–2013, 46 walk-in centres, 54, 240
stroke, 92f tolerance for change, low, 116 want (felt need), 78, 236
structured activities, 197–198 top down vs bottom up approach, Web sites see Internet
structured interview, 100 36–38 weight
summary touching people contact, 142–144 at birth, low, 237
of formal talk, 171b trade unions, 49, 226 excessive, presenting population
of written report, 109 training, 232 statistics, 152f
summing up community groups, 211 losing, media information,
conversation with client, 138–139 in health promotion, 57 154b
of evaluation (summative Healthy Living in the wellness model of health, 3, 6
evaluation), 72 Neighbourhood, 127 White Paper, 239
supply and demands, 79 see also education whiteboards, 148t
support transtheoretical model, 193–195 WHO see World Health
in change treasurer, committee, 125 Organization
in behaviour, 201 trigger materials, 186–187 whole-population approach (to
in overcoming resistance to trust see care trust; NHS trust public health), 240
change, 116 tuberculosis screening services, coronary heart disease, 85
community work, 211 85b Work, Health and Wellbeing
for project workers, 217 TV, 155–156 programme, 228–229
Index 251
workplace, health promotion health, 5–7 in local press, 157–158

policies, 228–229 health education, 18–19 letter to editor, 158–159
alcohol, 231b health promotion, 17–18 of material sent to clients,
workshops, Healthy Living in the health policies 145
Neighbourhood, 127 hospitals, 229–230 readability test, 150–
World Federation of Public Health prisons, 230 151
Associations (WFPHA), 48 urban settings, 230 reports, 108–110
World Health Organization (WHO), workplace, 228 of research, 101
46, 91, 240 writing
definitions and concepts of job descriptions in community young parents group learning
glossary of terms, 18–19 health project, 217 contract, 168b

Promoting Health

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Promoting Health

To Jon and Sara

Commissioning Editor: Mairi McCubbin

Angela Scriven BA(Hons) MEd CertEd FRSPH MIUHPE

First edition 1985

ISBN: 978 0 7020 3139 7

British Library Cataloguing in Publication Data

Library of Congress Cataloging in Publication Data

Working together to grow

Forewords vii 8 Skills of personal effectiveness 107

PART 1 THINKING ABOUT HEALTH PART 3 DEVELOPING COMPETENCE

1 What is health? 3 10 Fundamentals of communication 133

2 What is health promotion? 17 11 Using communication tools in health promotion

PART 2 PLANNING AND MANAGING FOR 14 Enabling healthier living 191

7 Evidence and research in health Index 241

Thinking about health and

What Does Being Healthy Mean

Being healthy means different things to different

EXERCISE 1.1 What does being healthy mean to you?

stress as important, or if you work in a smoking Lay Perceptions

Health and Medicine

World Health Organization 1999a promotion in a globalized world. http://www.dh.gov.uk/en/

Occupational standards in health promotion 26

Defining Health Promotion

Health promotion is about raising the health status

Health Organization (WHO) definition of health

Involvement in Public Health The Scope of Health Promotion

EXERCISE 2.1 Exploring the scope of health promotion

Fig. 2.2 Activities for health gain.

Health education Preventive

Fig. 2.4 A framework for health promotion activities.

high level of competence is needed in one-to-one

This requires competence in, for example, market-

This chapter establishes some of the key philosoph-

working conditions and unemployment? It is easy

4. The client-centred approach 5. The societal change approach

Table 3.1 Five approaches to health promotion – summary and example

Aim Health promotion Important values Example – smoking

has been used because it is a simple one that helps

EXERCISE 3.2 Identifying your health promotion aims and values

CASE STUDY 3.1 CASE STUDY 3.2

Eliminate choice a position to change their lifestyle, to have the

Generic ethical principles

values accepted as underpinning sound profes-

This chapter provides an overview of the people

all countries support the following health policy

National government International

Private preventive National voluntary

Local government National and local media

Police, probation, Health and Safety

Local community and National Health Service

Local branches of Commercial and

Institutions of Workplace employers

Fig. 4.1 Agents and agencies of health promotion.

the major intergovernmental and NGOs such as

Shifting the Balance of Power Within the NHS –

Primary care trusts NHS trusts

Primary health care Secondary health care

Community GPs Dentists Pharmacists Opticians Hospitals Mental Learning Ambulances

and improving local