HEALTH PROMOTION INTERNATIONAL
© Oxford University Press 1996
Vol. 11, No. 1
Printed in Great Britain
Theory in Health Promotion
Introduction
KATHRYN DEAN
Research and Training Consultant, Population Health Studies, Copenhagen, Denmark
DAVID MCQUEEN
Office of Chronic Disease, US Centers for Disease Control, Atlanta, Georgia, USA
In a field that is action-orientated, the subjects of
theory and methods may not be given high
priority by many. Health promotion evolved out
of a practice field using knowledge derived from
research conducted in other disciplines. The
focus often remains on interventions based
loosely on research findings, rather than on
creating the knowledge-base for action. When
there is relevant and valid knowledge available for
program development, prioritizing implementation can contribute to effective health promotion
action. On the other hand, if research is implemented that is not relevant to community health
needs or is flawed in design or execution, then
implementation not only wastes resources, it
might affect health negatively. Assuring a sound
knowledge-base for action is thus a prerequisite
for achieving health promoting policy and
practice.
The papers that follow in this special issue on
theory in health promotion take up these issues.
They grew out of presentations and discussions in
a 1992 workshop on theory in health promotion
held at the WHO Regional Office in Copenhagen,
with participants from many countries. The
papers do not cover all of the subjects taken up in
the workshop, and thus do not reflect the richness
of the discussions. Levin and Ziglio, who could
not attend the workshop have added a perspective on theory and practice. The papers address
issues for opening a broader debate in a field at
the crossroads.
Aaron Antonovsky is no longer with us, but we
are privileged to be able to include the paper,
based on his contributions to the workshop, that
he prepared before he died. It is an honor that one
who contributed greatly to shifting the public
health focus from disease to health participated in
our workshop, and that his paper continues to
challenge our thinking as the field develops.
UNDERSTANDING HEALTH PROTECTION
The purpose of including the papers in Health
Promotion International is to take up issues
related to the subject of using theory in health
promotion research and practice. The pieces in
this collection represent some of the diversity and
consensus in the field. While there is debate on the
relative importance of theory and research, there
is agreement that the focus of our endeavours
needs to be on health rather than disease. This
means that we need to shift the focus of our
theoretical perspectives which still largely stem
from a medical model of disease. There also
seems to be a consensus view developing that
health promotion theories need to be dynamic
and contextual in order to guide research^ that
improves knowledge about the real, complex
causal processes affecting health in communities.
On the other hand, there is quite diverse thinking
on: (i) the role of theory in health promotion; and
(ii) the sources of empirical verification of theory.
The role of theory is challenged by those who see
health promotion primarily as a politically driven
process. The sources of verifying theory range
from the experimental model of science to lay
perceptions.
Years before health promotion became a criti-
8
K. Dean and D. McQueen
cal part of public health, Aaron Antonovsky was
already challenging the dominance of illness and
disease as the right approach for understanding
health. He argued that we should study the
survivors of adversity rather than those who succumbed to disease. Antonovsky's concept of
salutogenesis is one theoretical perspective
relevant for health promotion research. Other
natural theoretical frameworks for guiding
research in the field include health inequalities,
lifestyles, and the health impact of environments,
both physical and social.
In his paper, Antonovsky points to the continued disease orientation and the dominance of the
risk factor model in health promotion research as
weaknesses. He illustrates his arguments with the
metaphor of the downstream versus upstream
orientation of health services, originally used by
Zola (1970) to illustrate the futility of health
services dominated by treating disease, and
subsequently developed to argue for focusing
health systems where 'the real problems lie'
(McKinlay, 1974) and for the development of
new theory and practice in epidemiology {Lancet,
199 A).
The limitations of the risk factor model are
taken up in several of the papers. The statistical
risk of a disease is not a subject of interest in a
salutogenic model. The goal is to understand the
forces involved in health maintenance. What are
these forces and how do we study them? There is
general consensus that these forces are covered in
the five content areas outlined in the World
Health Organization Ottawa Charter (1986):
Healthy Public Policy, Supportive Environments,
Community Action, Health Promoting Personal
Skills and Health Services Reoriented toward
Health Promotion. Here the conceptual basis is
found for developing theories to guide health
promotion and for developing educational curricula for the preparation of new types of health
researchers and practitioners.
RECOGNIZING COMPLEXITY
The five areas for focusing health promotion
research and action reflect another theme running through the papers: that the real complexity
involved in the causal determinants of health
protection needs to be recognized in research,
education and practice. The components of
Antonovsky's 'Sense of Coherence' theory implicitly reflect the interplay of personal functioning
and environmental influences that shape the
degree to which a person's world is perceived as
comprehensible, manageable and meaningful.
McQueen makes the complexity explicit by
outlining the dynamic and contextual components needed for building theories of health
behavior. To understand the forces contributing
to behavioral change, the time dimension must be
incorporated into research modelling the interactions between social and cultural influences.
Milburn picks up this theme when arguing for the
need to tap the richness, complexity and diversity
of lay experience in health promotion. Social and
behavioural influences occur in cultural contexts
that are not well recognized in health research
and programs. She emphasizes that new types of
research are needed, including more use of qualitative methods allowing lay people to define both
problems and solutions from their own viewpoints.
That education and research training must
reflect the real complexity that needs to be understood for effective work in the field is a subject
taken up by Kelleher. She emphasizes that many
disciplines contribute knowledge for informing
health promotion. Thus education in health
promotion must draw on the wide range of
knowledge and skills that study the complexity in
real life situations.
THE ROLE OF THEORY
We are reminded of the functions of theory in
advancing knowledge by McQueen. He also
emphasizes that many disciplines have knowledge
needed for understanding health protection and
thus for promoting health. Discussing the potential of interdisciplinary collaboration for building
more useful theories of health behavior, he
defines tasks involved in theory building that have
generally been neglected in theories of health
behavior.
Antonovsky, McQueen and Dean all warn
against simplistic dichotomies in theory and
research for health promotion. The rejection of
dysfunctional dichotomies (health or disease,
good or bad health behavior, individual or structural determinants, the influence of nature or
nurture, etc.) reflect again the recognition of the
complexity involved in health maintenance, and
that health promotion theory needs to reflect the
real forces inherent in causal processes.
The cholesterol example outlined by Dean
Introduction
illustrates the dangers of neglecting theory. No
theoretical logic was used to transfer statistical
correlations to causal processes and for investigating inconsistencies in research findings to
avoid the development of a misplaced and costly
population health strategy and interventions.
Only health promotion theories that build in the
interacting causal influences operating in the daily
lives of human beings can avoid misdirected
policy and program implementation.
Milburn discusses the weaknesses of academic
theories that do not recognize lay knowledge.
Decrying the general failure of existing theory to
tap the richness of lay theorizing, she calls for
more flexible approaches to theory building that
can move beyond the limitations of the biomedical risk factor paradigm to tap the wider
social and cultural systems. Her observation that
epidemiological risk is an objective and scientific
concept, while lay perceptions of dangers to
health are experiential, in light of the cholesterol
example, calls into question the traditional use of
the terms objective and subjective, and raises the
issue of what should be recognized as scientific
knowledge.
RESERVATION AND CAUTION
Levin and Ziglio do not share most of the
concerns regarding theory development. They
emphasize, consistent with the recognition of the
dangers of grand theory in several of the contributions, that the field cannot build on any single allencompassing theory. The need for theory in
health promotion has also been challenged by
others who believe that the field can merely
emphasize the applied.
A weakness of this perspective is that even
without engaging in an active process of theory
development, research and programs will be
carried out on the basis of implicit theory. For
instance, in the cholesterol example, the interventions are implicitly built on a theory of simple
causation of one biochemical marker on cardiovascular mortality.
If research is not guided by some set of theoretical assumptions, the result is analytic chaos. In
9
health promotion this means that the field would
become limited to action, devoid of a sound
knowledge base, and of reflection and evaluation.
A strategy, after all, is a theory of how to achieve a
goal based on assumptions about reality relationships. Tactics are practice based on a theory or
strategy.
Few, if any, of those concerned with the need
for theory-building in health promotion are putting forward the notion of a theory for the field. In
fact, no social science today seeks a grand theory.
Examples of a grand theory, like those developed
by Parsons or Marx, seem highly contrived and
simplistic in today's world. Similar concerns also
apply to notions about all-encompassing strategic
plans. There is a long history of comprehensive
planning in many countries. Serious misapplications and failures are well documented. The
extensive literatures on comprehensive planning
in the health and other sectors are one important
source of the interdisciplinary knowledge needed
for research, education and practice in the field.
Since valid knowledge is needed to inform
effective strategies, theoretically and methodologically sound research on the domains for
promoting health outlined in the Ottawa Charter
is equally as important as it is for the biomedical
domains that inform medical care policy and
clinical practice. Those concerned with theory for
the field of health promotion are seeking
processes of theory development for organizing
and integrating empirical observations reflecting
the causal forces in health protection.
REFERENCES
Lancet (1994) Editorial: Population health looking upstream.
Lancet, 343,429.
McKinlay, J. (1974) A case for refocusing upstream: the
political economy of illness. Proceedings of the American
Heart Association Conference on Applying Behavioral
Science to Cardiovascular Risk. American Heart Association, Seattle.
World Health Organization (1986) The Ottawa Charter on
Health Promotion. Canadian Public Health Associaton,
Ottawa.
Zola, I. (1970) Helping—does it matter: the problems and
prospects of mutual aid groups. Address to the United
Ostomy Association.