Abstract
In observance of having worked for going on five decades in the health promotion profession, this editorial shares fifty observations about the state of our field. In part one, I offer these first twenty five observations that focus on societal trends that have shifted how we frame our work and the movement from wellness to well-being. I reflect on why the wellness term fell out of favor, the roots of the well-being term and attendant definitions of health promotion. Seminal professional text books, popular readership books and key studies that have informed the health promotion discipline are reviewed. I summarize several conundrums that need solving for and conclude with calls to action for health promotion professionals.
On occasion I have been asked by those new to the health promotion profession, or by those looking to make a career move, for guidance on where to find the best opportunities in our field. As a contented generalist who has had the good fortune of having worked in nearly every role in our discipline, I usually encourage others to ply their skills broadly. Early in my career I worked in health education product development for a large private sector computer company. Since then, I’ve had a serendipitous career path. I’ve had jobs I trained for like program development, teaching, coaching, and conference planning. And, happily, I also swerved unexpectedly into stints in research, account management, administration, writing and public speaking.
I have had the privilege of working in health promotion for going on five decades so I feel adequately armed to offer fifty observations about our professional state of affairs. I’ll admit this editorial is something of an indulgence. After all, no one asked my opinion about our professional state of affairs and, unlike most of my editorials, this list doesn’t aim to shed light on an emergent trend or current issue. But another of the surprises for me along my professional journey was to have this chance to serve as Editor in Chief of one of our profession’s leading journals. Of greatest import, it affords me the honor of vetting influential studies and, along with our peer reviewers and my fellow editors, ushering forward papers we feel are deserving of our readership and could be influential in our field. A secondary happenstance that comes with this role is that of opining on whatever I think our readers might like to join me in musing about.
As I hope you will surmise from this unassuming list of observations, my opinion is that our impact as a profession has never been greater. I anticipate you will also conclude that our profession has many unmet challenges and that we must make a serious commitment to continuous improvement and professional development. Today’s trends toward incivility, deaths of despair and misinformation will call on our profession to exert ever greater moral courage in defense of truth and social justice.
Definitions of Our Profession’s Work Have Evolved, Albeit Glacially
1. The WHO definition of health has, since 1948, remained a beacon for the health promotion discipline. “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
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Many have tried, with limited success, to improve on this foundational paradigm and definition. 2. The WHO definition has been most prescient. Post the pandemic, autonomy and agency have been trending watchwords. “Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.”
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3. The definition of health promotion I cite most often is from Larry Green and Marshall Kreuter: “any combination of learning experiences designed to facilitate voluntary actions conducive to health.”
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The original definition referred to ‘behaviors conducive to health’ but was changed to the use of ‘actions conducive’ to capture the broader socio-ecological influencers of health. 4. Michael O’Donnell, the Editor in Chief Emeritus and Founder of this Journal, presents a definition that best prioritizes elements needed: “Health Promotion is the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health, and supporting them in changing their lifestyle to move toward a state of optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of learning experiences that enhance awareness, increase motivation, and build skills and, most important, through the creation of opportunities that open access to environments that make positive health practices the easiest choice.”
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5. The growth of artificial intelligence, genetic testing and personalized medicine will have a transformative impact in our field. I have argued that the convergence of genomics, health education and lived experiences will enable ‘precision health promotion.’ This I defined as: “the personalized design of lived experiences that foster improved health and well-being for individuals within the context of their families, organizations and communities.”
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What Became of Wellness?
6. Halbert Dunn coined the wellness term in the 1950’s. His book “High Level Wellness”, defined it as: “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable. It requires that the individual maintain a continuum of balance and purposeful direction within the environment where his is functioning.”
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7. By the 2000s, the wellness word had fallen out of favor due to concerns about commercial uses of the term for unproven solutions and the growing cadre of non-credentialed practitioners. Indeed, even Don Ardell, whose prolific writings are credited with having popularized the wellness term, is now, in a sad turn of fate, regularly condemning wellness. He argues, instead, for “REAL Wellness” (Reason, Exuberance, Athleticism, Liberty) and the merits of a secular society.
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8. When the wellness term is used to describe worksite wellness, some have concerns that the field has an inordinate focus on physical health and medical model oriented disease management solutions. A serious adjudication of worksite wellness shows it is actually ever more aligned with Dunn’s vision and WHO’s definition of health with attention paid to engagement, social connection, resiliency, thriving, purpose and cultures of health.
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9. In lieu of wellness, “well-being” is now the more often used term to capture broader outcomes of interest in health promotion. The well-being term, for many, feels more inclusive of outcomes such as belongingness, life satisfaction, community health and health equity. Trace the genesis of the well-being term and you’ll find it spawns more from political science and community organizing than from public health.
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10. The health promotion field draws from eclectic disciplines including health education and promotion, psychology, economics and other social sciences. This is a great strength as there is power in multidisciplinary approaches. Still, welcoming practitioners with eclectic training into the health promotion field is a weakness when those not formally trained in the discipline let science take a back seat to ideology.
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Well-Being as a Higher Ambition in Health Promotion
11. This is such a tired and trite premise: “People already know what they’re supposed to do, they just don’t do it.” Saying it bespeaks a lack of understanding of the tenets of our discipline. Foremost, if it is not voluntary, it is not health promotion.
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12. The Socio-ecological Model is a seminal framework for prevention that holds that health is influenced by the interactions between individual, community, societal and relationship factors. Even though it is a staple for the health promotion discipline, there will always been tension between ascribing individual vs social responsibility for health.
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13. Having had the chance to work with many human resources professionals with oversight for their organization’s health and well-being initiatives, I have observed it is usually their favorite responsibility. They are increasingly focused on environmental factors, though their sphere of influence is often limited per making needed policy reforms that would boost a culture of health.
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14. Trolls critical of wellness seldom name problems that haven’t already been raised by study authors in their paper’s limitations section. Trolls exhort about the obvious, but with vitriol and mockery. What rude bloggers want even more than getting attention is to be taken seriously. They don’t understand that their fraught pursuit of the former assures they won’t achieve the later.
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15. Given ours is a multi-disciplinary field, some of my favorite editorials have featured recommendations from a diversity of experts on the “best books”
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and “best health promotion studies”
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and “best worksite health promotion studies”
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that are informing our field.
Fundamental and Enduring Professional Resources
For those not formally schooled in health promotion, the following ‘fundamental resources’ are must reads for understanding the discipline. 16. “Health Program Planning, Implementation and Evaluation” By Lawrence Green, Andrea Carlson Gielen, Judith Ottoson, Darlene Peterson and Marshall Kreuter.
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17. “Health Behavior and Health Education: Theory, Research, and Practice” by Karen Glanz, Barbara Rimer and Frances Lewis.
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18. “Organizational Culture and Leadership” by Edgar Schein and Peter Schein.
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19. “Health Promotion in the Workplace” by Michael P. O’Donnell.
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20. “Saving Gotham: A Billionaire Mayor, Activist Doctors and the Fight for Eight Million Lives” by Tom Farley.
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Conundrums in the Field and Calls to Action
Countless factors influence health and most have impeded well-being for centuries and will likely do so for ages to come. Determinants of health and well-being like zip codes, racism, poverty, and education may feel outside the sphere of influence of many health promotion professionals. Nevertheless, inventing ways to address these intractable issues should be one of our highest professional aims. 21. Gender and race conscious hiring and diversity, equity and inclusion (DEI) initiatives are, astoundingly, suffering dramatic set-backs. Before “woke” was co-opted, it simply meant being awake to bias and discrimination. Our profession must do our part to rebrand woke and reboot DEI.
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22. Many business leaders are arguing for a new definition of the purpose of corporations that includes all stakeholders, not just stock holders. Yet, policies to advance environmental, social and governance accountabilities (ESG) are under siege. Our profession should take a leadership role in integrating ESG factors with well-being strategies.
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23. Both equality of opportunities and equality of outcomes are critical to advancing health and well-being. Our field needs to sharpen our social justice lens and ensure our efforts spur incremental steps toward equality.
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24. Body acceptance, body neutrality and ‘healthy at any size’ points of view could, for too many, cloud over the pernicious risks of obesity. Our profession must lead in combatting weight stigma while innovating in the kind of lifestyle advocacy that is antithetical to fat shaming.
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25. As much as this conundrums list is sobering, it is a privilege to be tasked to solve for health inequity and well-being disparities. If it’s not fun, it’s not health promotion.
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Row Better
My rowing coach carries a 30 Watt Megaphone inscribed with the simple admonishment, “row better.” Obviously, exhortation is not a strategy, but the message does capture the ‘why’ that keeps her coming to work. One belief that has permeated my professional life is that the job of health promotion is to mobilize people to make life better. 28 That I had professional opportunities to partake in several years of formal training in continuous quality improvement, mostly Kaizen, cinched that view. Related to this, I’ve also held that progress and innovation most often occurs when unlikely partners come together to advance shared values. 29 For newcomers to our profession, I often recommend they try all of the sectors. The public, private and non-profit sectors each offer unique opportunities to make things better. Every sector has a bottom line and accountability is paramount in any well led and managed organizations. For health promotion professionals, the bottom line that takes priority, regardless of sector, is improving the health and well-being of those we serve.