well as schools and communities were now seen as sites for action in health promotion (World Health Organization, 1998).
Stage 3: Multiple Levels of Influence on Health
The third stage of health promotion started at beginning of the 21st century with the realization that even within high income countries there could be a difference of almost 20 years in life expectancy—even in those countries that had a well-developed healthcare system providing care to all citizens (Kaplan et al., 2015). Individual decisions about health behaviors were rooted in the social environment in which people are born, live, work, and play (Marmot, 2005). The social institutions (economic systems, housing, healthcare system, transportation system, educational system), the surrounding environment, social relationships, and civic engagement all provide opportunities for individuals to make healthy choices—or not. One’s opportunities for a healthy life style are severely limited if there is no affordable low-income housing, no transportation infrastructure that allows individuals to pursue employment outside of their neighborhood, no supermarkets in the neighborhood with fresh fruits and vegetables, no safe parks in which to play or exercise, or no quality schools to provide a quality education in the neighborhood.
Today, health promotion is a specialized area in the health fields that involves the planned change of health-related lifestyles and life conditions through a variety of individual and environmental changes. Figure 1.2 illustrates the dynamic interaction between strategies aimed at the individual and strategies for the entire population.
Figure 1.2 Dynamic interaction between strategies aimed at the individual and strategies for the entire population
Source: Phase I Report - Recommendations for the Framework and Format of Healthy People, U.S. Department of Health and Human Services, 2020.
Healthy People 2030 : A National Public-Private Partnership to Promote Health
Every decade since 1980, the U.S. Department of Health and Human Services has reinstituted the same public-private process and released an updated version of Healthy People that provides the overarching goals and objectives that will guide and direct the health promotion actions of federal agencies; local and state health departments; and practitioners, academics, and health workers at all levels of government.
For individuals engaged in health promotion, one value of the Healthy People framework is access to national data and resources. Because the initiative addresses such a broad range of health and disease topics, health promotion program staff can usually find objectives that are similar to those they are planning to address in their locales. Using Healthy People information allows program staff to compare their local population data with national data and to use resources that have been generated nationally in order to achieve the national objectives.
Healthy People 2030 continues to expand the reach of health promotion, recognizing that many sectors contribute to the health of people. For Healthy People 2030, the World Health Organization’s definition of health promotion remains relevant. However, the emphasis shifts to the social and environmental opportunities for improving population health, as noted in the WHO definition of health promotion. That definition is more empowering, more aspirational, and less prescriptive than ones adopted in earlier decades.
Although individuals share some responsibility for their health, supportive environments make their choices easier. The United States has not made the progress over decades of work needed for improving health and eliminating disparities. To achieve different outcomes in this decade, Healthy People 2030 emphasizes and suggest different ways of prioritizing both time and money. Healthy People 2030 follows the lead of the Robert Wood Johnson Foundation to take a holistic approach to empower individuals and communities to take actions for their own health, foster leadership for public health, promote intersectoral action to build healthy public policies, and create sustainable health systems in society. It continues to recommend interventions at the personal, organizational, social, and political levels to enable changes in lifestyles, environments, and other realms to improve or protect health. Figure 1.3 illustrates how to use the Healthy People 2030 to promote health.
Figure 1.3 Using Healthy People 2030 to promote health
Source: Use Healthy People 2030 in Your Work, U.S. Department of Health and Human Services, 2020.
Health Education and Health Promotion
Health promotion has its roots in America in health education (Chen,2001). In the United States, health education has been in existence for more than a century. The first academic programs trained health educators to work in schools, but the role of health educators working within communities did not become popular until the 1940s and 1950s.
Health education promotes a variety of learning experiences to facilitate voluntary actions conducive to health (Green et al., 1980). These educational experiences facilitate gaining new knowledge, adjusting attitudes, and acquiring and practicing new skills and behaviors that could alter individual (one-to-one) or group instruction through personal online or group communication. Mass communication strategies can stimulate behavior change through public service announcements, webinars, social marketing techniques, and other evolving communications vehicles such as text messaging to blogging.
Health promotion has been defined as the combination of two levels of action: (1) health education and (2) environmental actions to support the conditions for healthy living (Green & Kreuter, 1999). Environmental actions prioritize populations in organizations and the community. Such environmental strategies and interventions include political, economic, social, organizational, regulatory, and legislative changes that can improve the health groups of individuals (Table 1.2).
Table 1.2 Components of Health Promotion Programs
| Health Education to Improve Individual Health | Environmental Actions to Promote Health |
|---|---|
| Health knowledge Health attitudes Health skills Social support Health behaviors Health indicators Health status | Advocacy Environmental change related to variables influencing health outcomes (e.g., education, transportation, housing, criminal justice reform) Legislation Policy mandates, regulations Financial investment in communities and other resource/community development Organizational development Criminal justice reforms |
The priorities for health promotion programs identified by the World Health Organization (1998) are advocacy for health to create the essential conditions for health, enabling all people to achieve their full health potential and mediating between the different interests in society in the pursuit of health.
Health promotion uses complementary strategies at both personal and population levels. In the past, health education was used as a term to encompass the wider range of environmental actions. These methods are now encompassed in the term health promotion, and a narrower definition of health education is used to emphasize the distinction.
Health education as a discipline has a distinct