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Revision notes 7.5

Section 7.5 Health promotion

Learning outcomes

Examine models and theories of health promotion.

Discuss the effectiveness of health promotion strategies.

For behaviour to change in any meaningful way, beliefs and thought processes also have to change. Therefore, social science researchers construct social cognition models to analyse why and how people behave in the way they do.

The health belief model (HBM)This model was first developed by Rosenstock (1966) although it has been modified and improved over the years by different researchers. It rests on the assumption that people will engage in healthy behaviour if they understand a negative health problem will arise if they do not. The key assumption is that people are rational thinkers – that is, they are capable of making and following choices that are in their best interest.

People will first evaluate a threat to their health (e.g. fast food) and then engage in a cost–benefit analysis of what actions to follow to either counter the threat or ignore it. Evaluations and cost–benefit analyses of this kind are examples of cognitive processes which the model is trying to influence to cause a change in behaviour.

However, there are a number of key problems with this model.

1 The HBM assumes people are rational when evidence is sometimes to the contrary. However, the HBM fails to consider how people often ignore commonsense solutions to everyday problems and wilfully engage in behaviour that risks their health. This may be partly due to the notion of positive illusions (Taylor and Brown, 1988) whereby people tend to be more optimistic than pessimistic about the world. Positive illusions are an example of optimism bias and encourage people to be over-optimistic about the outcome of their health-risking behaviour.

2 HBM assumes people care about their health or the health of those they care for. Health apathy can be defined as an absence or suppression of emotion, feeling or concern towards matters pertaining to personal health or to the personal health of people for whom other individuals are responsible. This

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would explain why people still engage in unhealthy behaviour such as eating poor food when they are obese and feeding poor food to others who are also obese.

3 The model ignores physiological determinism. Kessler (2010) argues food is deliberately designed with the use of chemical enhancers to make it compelling and create a bliss point for the consumer. Therefore, positive rewards are artificially instilled in the food to encourage consumption above and beyond the need to eat for energy intake.

4 The HBM approach assumes people are active thinkers able to make choices within the realm of freewill. However, it ignores the levels of aggressive marketing food corporations engage in, including establishing habits and tastes in young children who maintain their buying behaviour into adulthood. Otto and Aratani (2006) demonstrated how the banning of soft drinks, junk foods and sweets from school vending machines and cafeterias has improved the health of students in LA. However, this was achieved only in the face of determined resistance from food manufacturers.

5 The HBM considers only perceived obstacles to effective health regulation, not practical obstacles. Mair et al. (2005) cite Ashe et al. (2003) to show how fast food outlets are often in abundance in poor neighbourhoods where people are less likely to have personal transport for ease of access to a wider range of food choices.

Theory of reasoned action (TRA)Some of these criticisms are addressed by the theory developed by Fishbein and Ajzen (1975). The key assumption of this theory is people do not always indulge in behaviour that is in-line with their stated beliefs and intentions.

According to TRA, intention is the best predictor of behaviour.

Theory of planned behaviour (TPB)Ajzen (1985) modified the TRA into the TPB when he added the concept of perceived behavioural control. Including self-perception in this way strengthens the original theory as it adds another layer of a person’s own interpretation when assessing the likelihood of a planned behaviour being followed.

Self-efficacy theory (SET)Another important influence was the concept of self-efficacy, originating from Self-efficacy theory (SET) put forward by Bandura (1977).

Bandura notes people with a strong sense of self-efficacy:

view challenging problems as tasks to be mastered

develop deeper interest in the activities in which they participate

form a stronger sense of commitment to their interests and activities

recover quickly from setbacks and disappointments.


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People with a weak sense of self-efficacy:

avoid challenging tasks

believe that difficult tasks and situations are beyond their capabilities

focus on personal failings and negative outcomes

quickly lose confidence in personal abilities.(cited Bandura, 1994).

According to Bandura, self-efficacy is the most important condition to enact behavioural change.

The effectiveness of health promotion strategiesHealth promotion can be defined as the science and art of helping people change their lifestyle to move toward a state of optimal health (Minkler, 1989). It has always been associated with achieving greater health equity and eliminating health inequalities in society.

Measurement of outcomesHealth promotion strategies have to be assessed in order to determine their success and to influence future policy. Health status should be measured before an intervention is carried out, the intervention itself should be measurable, and then health status should be measured again after the intervention. This basic approach is known as measurement of outcomes and is based on a scientific experimental paradigm – Does cause lead to an effect? Has the variable that has been manipulated (the health intervention) lead to a measurable effect in terms of the improvement of health?

Evidence-based treatmentThe measurement of outcomes perspective uses an evidence-based treatment (EBT) approach and rests on the assumption that research into health campaigns has to produce statistically significant data to show an effect of the health strategy. It is an attempt to standardize the measurement of health and the effects of treatments or interventions.

The EBT approach considers the notions of efficacy and effectiveness.

Efficacy – The relative improvement in health as the result of an intervention in a controlled randomized trial (essentially a scientifically based approach).

Effectiveness – The relative improvement in health as the result of an intervention in a more realistic, everyday setting.

The EBT approach has many advantages.

Differences between efficacy and effectiveness can be identified.

EBT can help identify hazardous interventions which may only show up in large datasets.


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EBT is used to monitor changes during treatment over time. Setting up a scientific approach to data collection negates the effects of subjective variables such as memory by an individual patient or medical practitioner.

However there are some disadvantages:

EBT requires a clearly defined population and a reasonable control of variables within it. This is often unrealistic.

The slavish reliance on the underlying scientific principles of EBT is also unrealistic as many non-measurable variables (e.g. culture and self-belief) affect health outcomes.

Appraisals of health should always consider the everyday and personalized variables that may influence susceptibility to campaigns and the will power to adopt healthier personal habits. These are difficult to quantify.

Population health approach (PHA)Many health promotion strategies use a PHA. This can be defined as health promotion actions which are primarily targeted at the societal, community, structural or systems level. Any PHA has to take account of the various cultural and sub-cultural subtleties of groups in wider society. Such cultural groups may be defined by: gender, age, religion, sexual orientation, ethnic background, socio-economic background, dietary habits, and so on. For example, not everyone needs to be reminded about the dangers of eating too much processed food, and not all groups have access to exercise facilities such as a gym or a swimming pool, or be able to ride a bicycle to work.

Workplace health promotionThe workplace is a focused area for health promotion. This is an area where people spend a significant amount of time and it can influence mental, social and economic well-being. The programmes promote activities such as exercise and stress management, and provide information on nutrition and how to stop smoking. In this way, employees can be taken out of their various sub-cultural groups (they are all in the group of employees) and health information can be delivered through a workplace paradigm. Workplace health promotion is, therefore, very effective at reaching large numbers of people from different cultural groups who would not otherwise gather in one place.

Chapman (2005) conducted a review of worksite health promotion and outlined a series of meta-analysis studies published between 1982 and 2005. He found worksite health promotion produced, on average, a decrease of 26.8% in sick-leave absenteeism, a decrease of 26.1% in health costs, and a decrease of 32% in workers’ compensation costs. Another effective aspect of worksite health promotion is that it provides a large audience for health promotion messages.

Cognitive dissonance


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Cognitive dissonance is the uncomfortable feeling caused by holding two contradictory beliefs or ideas at the same time (Festinger, 1957). The inherent assumption behind cognitive dissonance is that people are driven to reduce conflicting feelings or thoughts by changing their attitudes, beliefs, and behaviours, or by justifying or rationalizing them.

Causing cognitive conflict in this way forces people to reflect on their lifestyle choices and begin a process of changing them or rationalizing them. However, people are also capable of using emotional dissonance to regulate their lives. This phrase was coined by Hochschild (1983) and refers to when people can maintain a fake emotion (one they do not genuinely hold) for presenting in public. Public health campaigns have to tackle cognitive processes (what kind of information is presented) and emotional processes (how it is presented). Information presented in a patronizing and demeaning way will be less effective than information which considers how people feel about themselves and their lifestyles.


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