Health Promotion
Health promotion is the process of enabling people to increase control over and improve their health, encompassing individual behaviour change strategies, community development, and population-level policy interventions as defined by the Ottawa Charter.
Key Facts
Ottawa Charter (1986) defined five health promotion action areas: build healthy public policy, create supportive environments, strengthen community action, develop personal skills, reorient health services Health promotion encompasses three approaches: medical/preventive, behaviour change, and empowerment/community development Behaviour change models: Health Belief Model, Transtheoretical Model (stages of change), Social Cognitive Theory, COM-B model NICE PH6 and related guidance provide evidence for behaviour change interventions in primary care Making Every Contact Count (MECC): brief opportunistic health promotion at every healthcare interaction Social determinants of health (Dahlgren-Whitehead model): socioeconomic, cultural, environmental conditions are the most powerful determinants Proportionate universalism (Marmot Review): universal services with intensity proportionate to need Inverse care law (Tudor Hart, 1971): availability of good medical care varies inversely with population need
Overview
Key Facts
Health promotion goes beyond individual behaviour change to address the wider determinants of health. It combines education, environmental modification, and policy change to improve population health and reduce health inequalities.
Approaches to Health Promotion
- Medical/preventive: immunisation, screening, risk factor identification
- Behaviour change: motivational interviewing, brief interventions, health education
- Empowerment: community development, peer support, self-management
- Social change: policy, legislation, advocacy (tobacco legislation, sugar tax, minimum unit pricing)
Levels of Prevention
- Primary prevention: preventing disease before it occurs (vaccination, health education, smoking cessation)
- Secondary prevention: early detection and treatment of disease (screening, opportunistic case-finding)
- Tertiary prevention: minimising impact of established disease (rehabilitation, self-management support)
- Primordial prevention: preventing risk factors from developing in the first place (addressing upstream determinants)
Behaviour Change Models
- Health Belief Model: perceived susceptibility, severity, benefits, barriers, cues to action, self-efficacy
- Transtheoretical Model (Prochaska & DiClemente): pre-contemplation → contemplation → preparation → action → maintenance (± relapse)
- COM-B Model (Michie): Capability, Opportunity, Motivation → Behaviour; underpins NICE behaviour change guidance
- Nudge theory: choice architecture to make healthy option the easy option
Clinical Presentation
Health Promotion in Primary Care
- Making Every Contact Count (MECC): brief intervention at every consultation opportunity
- Key topics: smoking, alcohol, diet, physical activity, mental health, sexual health
- Very Brief Advice (VBA): Ask, Advise, Act — applicable to smoking, alcohol, weight
- Motivational interviewing skills: express empathy, develop discrepancy, roll with resistance, support self-efficacy
- Social prescribing: linking patients with community resources (exercise, arts, volunteering)
Population-Level Interventions
- Tobacco legislation (smoking ban 2007, plain packaging 2016)
- Sugar tax (Soft Drinks Industry Levy 2018)
- Alcohol minimum unit pricing (Scotland 2018)
- 5-a-day campaign
- Change4Life and Better Health campaigns
- Active travel and urban planning initiatives
Differential Diagnosis
| Approach | Target | Example | Effectiveness |
|---|---|---|---|
| Individual behaviour change | Personal choice | Smoking cessation advice | Moderate |
| Community development | Social networks | Community cooking groups | Moderate |
| Environmental change | Physical environment | Cycle lanes, green spaces | High |
| Policy/legislation | Population | Sugar tax, smoking ban | Highest |
| Social marketing | Attitudes/norms | Change4Life campaign | Variable |
Diagnosis / Investigation
Evidence for Health Promotion
- NICE public health guidance provides evidence base for interventions
- Community-based trials and natural experiments increasingly used
- Cost-effectiveness analysis essential for resource allocation
- Health impact assessment: prospective evaluation of policy effects on health
Measuring Health Promotion Effectiveness
- Process measures: reach, engagement, participation rates
- Intermediate outcomes: knowledge, attitudes, behaviour change
- Health outcomes: disease incidence, mortality, disability
- Equity outcomes: reduction in health inequalities
- Patient-reported outcome measures (PROMs) and experience measures (PREMs)
Management
Key Policy Frameworks
- Marmot Review (2010): Fair Society, Healthy Lives — recommended proportionate universalism, early years investment, fair employment
- NHS Long Term Plan: focus on prevention, personalised care, population health management
- Core20PLUS5: NHS approach to reducing health inequalities; focuses on most deprived 20%, plus inclusion health groups
- Integrated Care Systems (ICS): collaborative approach to population health
GP Role in Health Promotion
- Opportunistic health promotion at every consultation (MECC)
- Structured chronic disease management with lifestyle advice
- Social prescribing referral
- Participation in public health campaigns (flu vaccination, cancer screening)
- Advocacy for patients and communities
- Contributing to local health needs assessments
Prognosis
- Population-level interventions (legislation, taxation) have the greatest impact on health outcomes
- Individual behaviour change interventions have modest but measurable effects
- Health promotion interventions are generally highly cost-effective
- Tobacco control is the most successful public health intervention: UK smoking rates halved from 46% (1974) to 13% (2023)
- Addressing social determinants has the greatest potential to reduce health inequalities
- Health promotion requires sustained, multi-level action across sectors
Other Relevant Information
Dahlgren-Whitehead Model (Layers of Influence)
| Layer | Examples |
|---|---|
| Individual factors | Age, sex, genetics |
| Lifestyle | Smoking, diet, exercise, alcohol |
| Social and community | Social networks, support, community cohesion |
| Living and working conditions | Housing, education, employment, healthcare |
| General socioeconomic, cultural, environmental | GDP, inequality, climate, food policy |
Transtheoretical Model (Stages of Change)
| Stage | Description | GP Approach |
|---|---|---|
| Pre-contemplation | Not considering change | Raise awareness |
| Contemplation | Thinking about change | Explore ambivalence |
| Preparation | Planning to change | Support plan development |
| Action | Making change | Reinforce, problem-solve |
| Maintenance | Sustaining change | Prevent relapse |
| Relapse | Return to old behaviour | Non-judgemental, re-engage |