Health promotion education in changing and challenging times: Reflections from England

Abstract

Health education has changed in many ways since Health Education Journal was first published, with developments moving the discipline forward in ways not envisaged 75 years ago. While there have been recent concerns about the decline in status of health promotion and linked worries about health education, the contemporary evidence base has grown to support the delivery of good quality health education and the development of capable and skilled practitioners. Pedagogy has further developed as well, and new technology now enables health education to have broader reach through online teaching and learning, social media and open-access publications. Global challenges remain, however, and the context in England is one in which both education and practice face major trials despite the contribution that health education has made by those educated and trained in this setting over a period of many years.

Keywords

Challenges England future health education health promotion opportunities

Introduction

Concerns about the perceived decline of health promotion have been reported across the world, and the field of activity has had a somewhat ‘chequered history in England’ (White and Wills, 2011: 44). Critical analysis of the discipline has paid attention to the crisis in health promotion in a political climate that is not well aligned to its principles and ideological basis, leading to calls for action to reinvigorate the discipline (Wills et al., 2008). More positive analyses suggest that health promotion education and practice provide opportunities to manage complex global health threats (Liyanagunawardena and Aboshady, 2017), such as climate change and other ‘wicked’ health issues, and to serve as forces for social change (White and Wills, 2011).

There have been many disciplinary developments that are beneficial for health promotion and the health education that is part of it. Furthermore, the scope and volume of health promotion research have been growing with resulting increases in associated publications (Lahtinen et al., 2005). Health Education Journal (HEJ) moved from four to eight issues a year in just 7 years and health promotion journals more generally report increased rates of submission of manuscripts from across the globe (De Leeuw, 2013; Potvin et al., 2013). Glanz (2017) also notes how the creation of the journal Pedagogy in Health Promotion is now enabling discussion of the art and science associated with teaching of health education. Thus, research (both pedagogical and otherwise) continues to develop and contribute to the field.

The terms health education, health promotion and health promotion education have varying definitions and have been debated for years without full international consensus being achieved. In the USA, no less than seven major terminology reports have been developed over an 80-year period in response to these ongoing debates (Report of the 2011 Joint Committee on Health Education and Promotion Terminology, 2012). Similar debates have taken place in other contexts. Traditionally, health education was about the communication of messages related to health, designed to inform people in general and enable learning different to the provision of education to develop health promotion competencies among practitioners (Seymour, 1984).

The term health promotion is defined within the Ottawa Charter (World Health Organization [WHO], 1986) as ‘the process of enabling people to increase control over, and to improve, their health’ (p. 1). In many countries, the term health promotion is seen to encompass health education, with health promotion education being part of a broader strategy linked to implementation (Taub et al., 2009). Health promotion education has also been defined by WHO (2017) as ‘any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes’. The focus of this paper is largely on educational provision for practitioners, but given that health promotion education is also part of practice (i.e. of health promotion itself), this broader context is included within our discussion.

Space for health promotion education has positively developed since HEJ was first published in its current form in 1943.¹ Now and much later, it serves as a support for those working in both education and practice. However, in this article, we argue that major challenges remain in England and other countries for health promotion education and its associated practices, which we understand to encompass the practical development, application and evaluation of health promotion interventions, based upon education. In this paper, and using the opportunity provided by HEJ’s anniversary, we reflect upon the current state of health promotion education (primarily taught via credit-bearing programmes) in England, offering comparative analysis and critical discussion of the importance of political context in determining health promotion education priorities and practice.

Contemporary health promotion education

The evolution of health promotion education

Improving the health of individuals and communities has been a priority for countries all over the world, and this concern remains evident today. Health education and promotion have evolved into a profession that involves training, certification and the evaluation of practice. The origins of these educational developments in England have been discussed by Duncan (2013), who noted the contribution during the 1970s of a small number of scholars in polytechnics and colleges who developed curricula that laid the theoretical foundations for the practice of health education and health promotion. Since then, with the significant amount of attention that has been paid to health determinants, it has been argued that health promotion experienced a golden age (Johnson and Breckon, 2007). Some analyses support this view. However, the situation is less positive when focusing on contexts such as England.

The professionalisation of health promotion as a discipline has resulted in the development of new quality assurance approaches and guidance underpinning the creation of curricula. The UK Public Health Skills and Knowledge Framework (Public Health England [PHE], 2016) outlines the core skills and competencies required of the public health workforce. The framework provides a common reference for the review and development of standards of practice and curriculum for training and education qualifications for those working with public health remits. While standards and guidance are useful, questions remain about their fitness for contemporary educational purposes. At the European level, there is wide variance in the development of training, occupational opportunities and the extent to which health promotion specialisation is required, despite the existence of these professional standards (Taub et al., 2009). Indeed, the content of such education is often debated. Yassi et al. (2017) note that providing practitioners with interdisciplinary knowledge about the ecological threats to health is not enough. Educational provision within this field is about competency development for impactful practice, rather than simply increasing awareness of key concerns. Educational approaches need to ensure that opportunities are provided for the modelling of attitudes and commitments to support both community engagement and suitable policy-making, thereby ensuring that health promotion education is firmly embedded in practice contexts.

It has been suggested that classroom teaching for health promotion is less relevant, given the age of the Internet, new forms of social media and access to ever greater levels of information. Learners’ expectations have also changed, challenging educators to diversify their approaches. Hence, there may be a need to adapt teaching to include online methods, fieldwork and blended approaches (Glanz, 2017). However, traditional styles of health education remain relevant to many. For example, action learning and classroom delivery still have their uses, especially in contexts where these are learner preferred modes of instruction. There, therefore, needs to be a balance between the old and the new while recognising the many opportunities that technology can offer to both health education and practice.

Workforce challenges in England

Due to political factors, the demand to train a ‘health promotion’ workforce is no longer what it was in England, in contrast to the situation in some middle- and low-income countries. For example, in Ghana, the Ministry of Health actively supports health promotion, seeing it as valuable in engaging with the social determinants of health (Addei et al., 2012; Klutsey, 2010). Ghana has a clearer structure for the organisation of its health promotion workforce, although this is under-resourced as is typical in similar contexts. In Zambia, a relatively recent change of government has signalled renewed interest in health promotion (The Health Press, 2017). This change has led to a demand for health promotion training to better equip the workforce. While both countries are working hard to increase the capacity of the health promotion workforce through in-country training, there remains high demand for courses provided in high-income countries. Dixey and Green (2009) describe a partnership between a training college in Zambia and a UK University as one means of tackling the sustainability of the health workforce in Zambia in response to ‘brain drain’. The partnership offered opportunities for in-country professional public health development through educational provision which was well received and strengthened workforce capacity (Development Solutions, 2014). This contrasts with the reduction in workforce budgets for health promotion education in England, potentially stagnating learning and development among practitioners.

Online approaches and access

The development of massive open-access online courses (MOOCs) has opened up access to health promotion education for many. This kind of provision is a positive means of addressing some of the education and training difficulties experienced particularly in economically poorer areas of the world, enabling access for health professionals as well as the wider public (Liyanagunawardena and Aboshady, 2017). Given the health challenges facing low-income countries, including the increasing burden of non-communicable diseases, health education is arguably of great importance. There is now a range of free online courses which have been useful in educating workers about Ebola (Coughlan, 2014). E-learning too is capable of addressing existing gaps in educational provision and potentially tackling in-country challenges, including cultural barriers to the open discussion of sexual health promotion (Liyanagunawardena and Aboshady, 2017). However, despite the potential of these options, there are issues in terms of uptake, with linguistic and cultural barriers at play, as well as limited access to digital technology and low levels of Internet connectivity (Aboshady et al., 2015). Moreover, critical analyses of MOOCs show high numbers of students enrolling but far fewer completing, and problems with both learning processes and assessment have been highlighted (Keramida, 2015). Liyanagunawardena and Aboshady (2017) argue for the further development of MOOCs to meet the needs of specific populations by tailoring courses to different language requirements and including downloadable content to further unlock the potential of these approaches. The landscape of health promotion and its associated reach is changing, with the digital development offering important opportunities as well as challenges (Lupton, 2014).

Comparatively speaking, much health education in high-income countries has remained the same for many years, leaving gaps between the theoretical ideas underpinning health promotion education (empowerment, social change and the importance of bottom-up approaches) and the reality of everyday practice which is now more focused upon individual behaviour change (Whitehead, 2004). Furthermore, the development of health promotion education has been accompanied by an increased demand for effective interventions, for example, in relation to behaviour change (Laverack, 2017), health status indicators (Kok et al., 1997) and, more recently, social return on investment (Masters et al., 2017). Evaluation research is often a standard component of health education modules within university credit-bearing programmes, with a view to enabling practitioners to support demonstrations of effectiveness. However, this is complex territory and may not be positive for the discipline given that effectiveness is context-dependent and proving effectiveness can be difficult. Current health promotion practice, then, is linked to the impact of shifts within policy direction and market forces.

The impact of market forces

The provision of health promotion education and training by rich Western countries has also received critical attention because of costs and the continued dependency it encourages. Brown’s (2015) analysis of the changing higher education landscape since the 1980s when the process of marketisation began notes the introduction of student fees, subsequent price rises, changes in research funding and the reduction in subsidies in several areas. The UK’s Coalition Government (2010–2015) advanced the speed of this process by further increasing fees, deregulating student number places and relaxing market entry rules. Ultimately, the cost of education is now predominantly borne privately, while questions remain about how these changes relate to efficiency, effectiveness and innovation. Higher education can produce many benefits (McMahon, 2009) and can be for the social good in subject areas such as health promotion given the potential to develop future practitioners and contribute to social justice, health improvements and human rights. However, the marketisation of the setting in which health promotion education is delivered severely restricts the number of students who can afford to access qualifications and changes the social composition of the student body. Feo (2008) argues that in public health training, education has now become a ‘consumer good to be acquired in the marketplace’ as specialist training, being only available at the postgraduate university level (p. 227).

The marketisation of higher education has also had an impact upon working conditions for health promotion staff in England. Allimer (2017) has noted the blurring of work and personal time and increased job insecurity across the sector. Beyond universities and colleges, however, there have been suggestions that England is facing a mental health crisis in the workplace, with many workers suffering from anxiety and depression (Isherwood, 2017). A more positive reflection on current higher education provision, however, would suggest that so long as postgraduate provision remains university-led, quality and standards will be retained alongside the development of skilled and reflective practitioners. Some UK universities are also working to build health promotion capacity in low-income countries through distance learning and blended curriculum development, thus offering broader scope and opportunity than critics recognise. However, distance learning courses in UK universities charge expensive fees, and thus, not everyone can afford to access them.

In terms of UK health promotion education, the reducing number of undergraduate and postgraduate courses which include the term ‘health promotion’ in their title is evidence of health promotion’s general demise. This has been accompanied by a greater focus on masters’ degrees in public health in some institutions. Many of these focus less on education and the social determinants of health than on specialist medical concerns. Despite its continued presence, health promotion is simply not ‘in vogue’ in England like it is elsewhere in the world. Scotland and Wales seem to be in a slightly different position, which may be attributable to more progressive political agendas (Thompson et al., 2017). The changing policy context affecting higher education and therefore health promotion education delivery is, therefore, reflective of a broader administrative turn, raising further questions about the nature of the challenges facing the discipline.

Policy contexts, health education and health promotion

Policy in England

The future of health promotion in England has received critical attention because of structural reorganisation whereby in 2013 practitioners were moved from employment within the National Health Service (NHS) into local authority control, with much of their work becoming fragmented as a result. White and Wills (2011) argue that there is no comprehensive picture of the impact on health promotion practice resulting from recent policy changes such as the commissioner/provider split and the introduction of a health care market under the New Labour government between 1997 and 2010. Since 2013, under UK Coalition governance, decision-making and provision in relation to public health have shifted from the NHS to local authorities (Kneale et al., 2017). The Government White Paper, Healthy Lives, Healthy People (Department of Health, 2010), outlined a ‘new era for public health with a higher priority and dedicated resources’. The NHS Five Year Forward View (NHS England, 2014) argued for ‘a radical upgrade of prevention and public health’. However, despite positive policy discourse in relation to public health successive government being focused on structural reforms and efficiency savings (Kings Fund, 2015), public health has remained the poor neighbour in terms of priority setting as has so often been the case.

The initial shift of responsibility for public health practice to local authorities in England in 2013 involved the creation of a ring-fenced budget approach for dedicated health promotion programmes and interventions, arguably serving as an opportunity for a broader base of work encompassing health determinants such as housing, open spaces, education and the creative arts (White and Wills, 2011). However, this is no longer the case following the implementation of austerity, a policy approach which involves cuts to public expenditure, and an associated reduction in public service provision. The British Medical Association (BMA, 2016) note that the combination of austerity and welfare reforms within the UK has resulted in reduced public spending on health through budget cuts to specific departments. Local authority budgets have been reduced by central government, as have been the resulting public health ring-fenced allocations. The Kings Fund (2017) notes that central government cuts have impacted (albeit unevenly) public health services, with less provision now being funded in areas such as smoking cessation and alcohol and drug use services. Public health funding was reduced by £200 million in 2015–2016, and it is proposed that a further £600 million will be cut by 2020–2021, with local authorities having to make decisions about which services they fund and which they do not (RSPH, 2017). Within this context, it is likely that the current requirement for evidence of effectiveness will be used to support budget cuts (Kneale et al., 2017). While policy-makers frequently note the importance of preventing ill-health, this is not supported by associated funding. The majority of health funding in the UK remains spent upon treatment services rather than prevention (BMA, 2017).

Given that the Ottawa Charter for Health Promotion (WHO, 1986) identifies both enabling and empowering ways of working to support individual and community health, including community development, the overall policy context in England since 2005 has eroded the broader practice base of health promotion, with a resulting implementation of silo working, fragmented delivery and a narrow disciplinary focus on behaviour change, somewhat contrary to the discipline’s founding ethos. The impact of the UK policy changes has been to halt progress in reducing inequality and poverty and to increase negative health and well-being outcomes, due to a lack of focus upon health in all policies (BMA, 2016). Policy-makers need to pay close attention to the impact that austerity and fiscal policies have upon health and associated outcomes, given that recent policies have undermined health promotion (Ifanti et al., 2013). However, this seems unlikely currently in England given the more immediate issue of Brexit and its potential impacts.

The wider international policy context

There have been broader policy changes worthy of note within the broader global arena. Recently published European and international health promotion agreement signal continued support for the discipline and related forms of health education. The Vienna Declaration on Public Health was adopted at the European Public Health Conference in November 2016 (European Public Health Association [EUPHA], 2016). The Shanghai Declaration on Promoting Health in the 2030 Agenda for Sustainable Development was also adopted in the same month at the Ninth Global Conference on Health Promotion (WHO, 2016). The Vienna Declaration identifies key issues to be addressed in health promotion and offers contemporary guidance to the public health community (Tilford, 2017). In particular, it advocates an updating of the Ottawa Charter and a refocusing on civic renewal at community level, together with wider health education provision to ensure greater health literacy. The Shanghai Declaration, on the other hand, points to the need for universal health coverage and strengthening global governance to deal with health issues across borders.

Health promotion practice also remains strong in contexts across Sub-Saharan Africa, with health education in high demand within these areas. Health promotion in England has followed a different trajectory to that pursued in other high-income, global north countries such as Canada, Norway and Australia. In these countries, health promotion is arguably faring better in comparison (Thompson et al., 2017; Wise, 2008), although there exist critics in these contexts as well (Hancock, 2011). National or regional publications such as the Australian Journal of Health Promotion and the Scandinavian Journal of Health Promotion provide testimony to this. In Norway, the 2017 Public Health Act is underpinned by health promotion principles (Fosse and Helgesen, 2017). Perhaps these differences are, at least in part, due to national political drivers. In England, we are witnessing a move away from social and liberal values and the consequent systematic dismantling of the welfare state (Thompson et al., 2017). The focus on the individual in public health policy at the expense of the structural factors determining and influencing health is evidence of this.

Current policy direction in some contexts such as England and Greece has been criticised for being excessively neoliberal in its focus. Neoliberalism through market advancement and capitalist restructuring in pursuit of economic growth has been ongoing since the 1970s (Maskovsky and Kingfisher, 2001). However, analyses treating neoliberalism as a totalising discourse govern everything needs careful consideration (Carter, 2015: 375), especially since other more positive discourses about community health and well-being exist. Johnstone (2017), for example, notes the potential of community assets to improve health and well-being, and the related development of new resources by Public Health England, including detailed guidance on community engagement (National Institute for Health and Care Excellence [NICE], 2016) and the family as approaches to promoting health and well-being (South et al., 2015). The advent of the Sustainable Development Goals is also worthy of note. These are a new, universal set of goals, targets and indicators for use by United Nations (UN) member states as a mechanism to shape their own policy and practice until 2030. The goals are broad in scope and signal the importance of tackling growing wealth (Melamed and Ladd, 2013). The implications of these goals for health promotion imply an articulation of the principles underpinning the Ottawa Charter from 30 years ago and therefore provide a window of opportunity for health promoters in practice (Eckermann, 2016). Thus, if drawn upon, they offer some challenge to neoliberal policy direction.

Libertarian paternalism has also entered policy discourse in approaches that seek to nudge individuals in a healthier direction (Jones et al., 2013). Simply noting, however, that neoliberalism is affecting health promotion, or that the discipline itself contributes to it including through its educational focus and content, is insufficient as a form of analysis (Bell and Green, 2016). For example, suitable educational content can raise questions about a neoliberal account by emphasising the value of commonly agreed-upon charters and the reduction of inequalities. It can also focus on the importance of evidence-based practice and the success of small-scale projects in discrete settings which are at odds with newly dominant perspectives (Thompson et al., 2017).

Ayo (2012: 104), for example, argues that the manner in which health promotion is employed in Western neoliberal societies reflects and reinforces the prevailing political ideology. Health promotion practice can be described as a product of social, cultural and economic influences which in some contexts are at odds with the value base of the discipline at the point of its establishment. Questions remain about these discourses and to what extent they side-line the broader social determinants of health and approaches that focus upon social justice (Carter, 2015). Despite negative policy discourse being viewed as a challenge to health promotion education and related practice, there are some positives to note. Given increasing societal concern about health, health promoters and educators are still presented with the opportunity to promote both health and well-being.

Changing discourses and implications for practice

For good or for bad, health promotion has the attention of policy-makers, institutions and the media (Ayo, 2012). Being healthy and pursuing a state of healthiness are engrained within the dominant discourse of contemporary Western countries, particularly in England. However, critical commentators suggest that contemporary politics is driving health promotion to the level of the individual (Crawford, 2006). Healthism as an ideology implies that individuals should work personally to maximise their own health (Peterson and Lupton, 1996), which in turn will be beneficial for the wider society and cost the state less.

There are clear moral tones here. While there may be benefits to healthy behaviours such as physical activity and nutrition, critical attention should be given to the push for self-regulation and individual control at the expense of the social determinants of health (Ayo, 2012). Health promotion and education interventions in England follow a similar pattern, targeting individual-level behaviour rather than more pervasive social influences. Thompson et al. (2017) offers us the example of specialist projects to deal with homelessness in inner-city areas. These promote health-related outcomes but fail to address the root causes of homelessness using available political and institutional means.

How then can health promotion education work to challenge this? Some health education courses are indeed based upon the social model of health and ensure that the politics and policy of health underpin module content as a means to educate future practitioners about the social determinants of health. There is also a large and growing evidence base demonstrating the continued importance of social inequality and the social determinants of health, with key thinkers such as Marmot (2017), Wilkinson and Pickett (2009) and Shrecker and Bambra (2015) driving forward thinking in this respect. A theoretical agenda remains within the health promotion research literature as well as in some forms of educational provision, for example, courses underpinned by the social determinants of health, which can be used by educators to encourage upstream thinking among practitioners and which may serve as a starting point for new forms of social activism (Whitelaw et al., 1997). However, the wider political and societal context has led practitioners to report ‘moral distress’ caused by being part of a minority workforce within a broader system that does not value their input (Sutherland et al., 2015) – and this is despite WHO (2016) citing the clear need to develop a workforce which is able to tackle the social determinants of well-being and health.

The continued need for health education and health promotion

While challenges remain in the current political context, health promotion education and health promotion practice have much to offer those wishing to reduce inequalities, improve health and challenge consumerism and individualism (Feo, 2008). An increasing number of policy-makers recognise the need to move to more preventive models, especially if they can achieve savings, which leaves scope for new forms of education and practice. Nearly 30 years ago, Tones et al. (1990) outlined the case for health education as a means to learn about health, culture and experience so that benefits might accrue for the prevention of illness. The same authors noted an increasing concern with economic growth and productivity in Britain. Both of these issues remain pertinent at the 75th anniversary of HEJ in 2018. There does indeed remain much work to be done (Thompson et al., 2017).

The current state of the world’s health, the persistence of inequalities, the growing political turmoil, and the number of people who live in the absence of basic human rights offer new starting points for health promotion education and practice. As Sim and Mackie (2016: A1) put it, ‘We have to stand together to present the evidence for health, not the sometimes dangerous rhetoric of would-be power’. Contemporary health promotion education provides an opportunity for transformational learning related to the importance of the social determinants of health, the need to challenge victim-blaming culture and the associated hardening of social attitudes, as well as the lessons learned from understanding health as inherently political (Bambra et al., 2005). Success in this endeavour calls for the communication of knowledge (via health promotion education) of the wider factors at play which determine health, such as political and commercial factors, trade rules, welfare policies, economics and the environment (Van Schalkwyk, 2017). Given these many challenges, Erwin Campbell and Brownson (2017a) suggest that public health practitioners gain additional training in skills such as policy analysis, evaluation, cross-sectoral working and communication. While the world is in a state of flux, the health education curriculum can be used to equip future practitioners for this task. Further development of the field – both as a profession and as a discipline – is required to enable people to act. Health promotion education requires a scaling up to ensure skilled professionals are provided with appropriate competencies (Petrakova and Sadana, 2007). Yassi et al. (2017) argue for a defrosting of older paradigms (with their focus on redesigning educational provision) in the teaching of population and public health specifically within the Canadian context. They argue that all educational courses need now to include interdisciplinary enquiry and approaches to support the development of skills so that practitioners can work with communities, both implementing and evaluating interventions as mechanisms to create collective health. More generally, the knowledge, attitudes and skills taught need to be revisited in order to be able to respond to contemporary challenges. The importance of health education and health promotion learning is central to tackling the many challenges observed, as it underpins workforce development (Welter et al., 2017) which can in turn serve to improve population health (Koh, 2010).

Conclusion

If successful health promotion education is about developing practitioners who embody the values of the Ottawa Charter (WHO, 1986) and who understand the need to tackle the social determinants of health, how best can universities and other settings produce workers who do not feel stifled by the broader economic and political contexts in which they work? And is there a mismatch between the ideological basis of health promotion and current policy direction, particularly within in England? These questions remain central to the discipline, and while debate continues, health promotion education remains needed. When effectively applied, it can serve to inform knowledge, deliver transformational learning, support advocacy and produce skilled, robust and capable practitioners with problem-solving skills. Demand for health education is evident globally, and given the numerous health challenges that face the world, a case can readily be made for health promotion education and its associated practices.

Increased knowledge about health and digital developments, which offers tools to communicate evidence and wider reach to educate, provides new opportunities for health promotion education. While some contexts encounter challenges to health promotion education and practice because of neoliberalism, marketisation and current policy directions, this does not ultimately diminish need. Thompson et al. (2017) argue that the principles of the Ottawa Charter need relaunching within England to ensure a stronger emphasis on health inequalities and their remediation. This may be a starting point for ensuing that health promotion education better matches both service need and the wider practice context.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

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