A brief history of health Education and Health Promotion

1. HISTORY OF HEALTH EDUCATION
AND HEALTH PROMOTION
Col Zulfiquer Ahmed Amin
M Phil, MPH, PGD (Health Economics), MBBS
Armed Forces Medical Institute AFMI)

2. A search for the origins of health education and health promotion
leads to the earliest civilizations.
The writings of the Babylonians, Egyptians, and Old Testament
Israelites indicate that various health promotion techniques in
relation to shelter, food, water and safety were utilized.
There were community systems to collect rain water or otherwise
provide safe drinking water.
EARLY ORIGINS

3. There were various sewage disposal methods, including the
use of earth closets. Personal cleanliness was advocated.
Intoxication was recognized as troublesome. Dietary
restrictions were numerous, and various sanitary restrictions
governed the supply and preparation of food. Exercise was
advocated. In some places building regulations were set, and
street cleaning and garbage removal began to occur regularly.
Mental health and spiritual health (e.g., a sense of harmony)
were advocated.

4. In most early civilizations, health and religion overlapped.
Organized religion sponsored many of the earliest health care
facilities and practitioners of the healing arts. In some
civilizations, the first temples were also the first hospitals.
Regardless of the motivation, religious practitioners’ desire to
improve the health and well-being of others has been a powerful
force in the history of medicine, health education, and health
promotion.

5. Histories of Public Health show that some form of collective
public health measures have always been implemented by
societies, although these would not have been called Health
Promotion.
Examples include:
The Roman public baths.
Roman laws governing burial of the dead and regulating
dangerous animals and unsound goods.
The regulation of prostitution in Ancient Rome and Greece.
Inoculation against smallpox in India and China before the
Christian era.
The isolation of people with leprosy in Europe in the Middle
Ages.
The quarantining of ships by the Venetians.

6. Early Public Health
Movement
20th Century
Medical Era
21 Century
New Public Health
Movement
Advocated Housing,
sanitation, Food
Supplementation for
Poor communities.
Focused on structural
and environmental
measures to reduce
disease burden.
Emphasized developing and
using medicine to treat and
prevent ill-health, resourcing
tertiary hospitals and scientific
research.
1970: Medical
Model & therapeutic
Approaches questioned
1974: Lalonde Report-
Symbolized start of new
PH movement
-1900- -1970- -1980- -1990- -2000-
Health Education Health Promotion
19th Century

7. The Early Public Health Movement in Europe
The roots of today’s health promotion programs lie in the
Industrial Revolution (Period from about 1760 to sometime
between 1820 and 1840). The creation of large factories meant
that thousands of people were brought together in congested,
unsafe worksites located in congested, unsafe cities.
Science and technology have had a significant impact on
prevention by providing an understanding of the causative roles
of pathogens and how to immunize people. Similarly, discovery
of the effects of diet, exercise, and substance abuse on chronic
disease led to the evolution and elevation of prevention
programs.

8. In Northern Europe, the Industrial Revolution (late 18th century in
Britain), resulted in massive changes in population patterns and in
the physical environment in which people lived.
In Britain, the overcrowded and unsanitary living conditions of the
poor, coupled with the rise of cholera and typhoid as major causes
of death, placed pressure on the government to introduce reforms
or legislation to promote public health. In 1842, Edwin Chadwick,
who was responsible for leading a “Health of Towns Commission”
and advocating for the first public health reforms, suggested that the
ill health experienced by the poor was a result of poor housing,
sanitation and unclean water. His efforts resulted in the 1848 Public
Health Act.

9. It was around this time (1854), that the now-famous incident
involving John Snow, one of the first epidemiologists, took place.
Snow discovered that cholera was a waterborne disease, by
tracing an outbreak to a water pump in Broad Street, Soho,
London. When use of the water pump was stopped, the
outbreak stopped. Experiences such as these, together with
public health legislation led to the appointment of Medical
Officers of Health by local authorities, to enforce public health
legislation and advise on appropriate measures.

10. The rise in popularity of the Medical Model
Motivations aside, at the end of the nineteenth century, the
emphasis on improving environmental and social conditions in
order to prevent ill-health was overshadowed by the rising
popularity and investment in a medical (or curative) approach to
tackling ill-health.

11. Questioning the Medical Model
The social climate of the 1960s and 1970s was characterised by
protest, activism and challenging of the status quo or existing
conditions. In addition, during the early 1970s, many countries
were experiencing a crisis in health care costs. People began to
consider that whilst medicine might be good against acute
illnesses like TB or pneumonia, it did not appear to have much to
offer in other areas such as cancer. The rates of cancer were still
the same and there was still no cure for the disease. Thus, value
or returns from the investment in medical technology appeared
to be decreasing.

12. Questioning the Medical Model
An important hypothesis or theory proposed by Thomas
McKeown (1976) re-confirmed the importance of non-medical
factors in improving the health of populations in industrialised
countries.
IN A BODY OF RESEARCH published from the 1950s to the 1980s,
the physician and demographic historian Thomas McKeown put
forth the view that the growth in population in the industrialized
world from the late 1700s to the present was due not to life-
saving advancements in the field of medicine or public health,
but instead to improvements in overall standards of living,
especially diet and nutritional status, resulting from better
economic conditions. The “McKeown thesis” sparked the
inquiries and shaped the research hypotheses of many scholars
and became the subject of an extended controversy.

13. The New Public Health Movement
The Lalonde Report (1974) is the first major landmark in what came
to be known as the New Public Health Era. This report suggested that
greater emphasis should be attributed to the environment and to
behavioural factors as causes of disease and death, rather than
biophysical characteristics.
The Lalonde Report described four health fields as having an
influence on health and illness:
- Medicine and health care services.
- Lifestyle or behavioural factors.
- The environment.
- Human biology.

14. Health education has traditionally been used to refer to
educational interventions. The basic approach evolved from the
moralistic (“Don’t do it because God or the church doesn’t want
you to.”) to the legalistic (“Don’t do it because it’s against the
law.”).
With this shift, educational programs began to focus on possible
harmful effects of certain substances or behaviors and why they
were illegal. Of course, one objective was to explain what would
happen to lawbreakers if caught. Another was to urge legislators
and others to engage in social engineering, such as passing laws
mandating safety-related provisions, such as the use of air bags.

15. The educational process has changed as well. The original
models were cognitive (presenting the facts), but they were
replaced by affective models (changing attitudes), peer-
counseling and peer support models, decision-making models,
and, most recently, behavioral models.

16. WHO: Global Strategy for Health for All by the Year 2000
(1977), and the International Conference on Primary Health
Care, Alma-Ata (1978)
In 1977, the thirtieth World Health Assembly decided that the
main health-related goal of governments and the World Health
Organisation in the coming decades should be directed at
ensuring that all the people of the world attain a level of health
that would permit them to lead socially and economically
productive lives. This became know as the Global Strategy for
Health for All by the Year 2000 (HFA 2000). The significant
feature of HFA 2000 was the recognition that the main
determinants of health lay outside the health sector - namely
food, water, sanitation, housing, employment etc.

17. International Conference on Health Promotion, Ottawa,
Ontario, Canada (1986)
In 1986, the first international conference on Health Promotion
was held in Ottawa, Canada. The Ottawa Charter for Health
Promotion outlined five areas in which Health Promotion action
should be directed:
- Building healthy public policy.
- Creating supportive environments.
- Strengthening community action.
- Developing personal skills.
- Re-orienting health services.

18. GLOBAL CONFERENCES ON HEALTH PROMOTION
Conference Venue Year
Ottawa Charter of Health promotion Canada 1986
Adelaide Recommendation on Health Public Policy Australia 1988
Sundsvall Statement on Supportive Environment for
Health
Sweden 1991
Jakarta Declaration on Leading Health Promotion into
the 21st Century
Indonesia 1997
Mexico Ministerial Statement for the Promotion of
Health
Mexico 2000
Bangkok Charter for Health Promotion in a Globalized
World
Thailand 2005
Global Conference on Health Promotion, Nairobi Kenya 2009
Global Conference on Health Promotion, Helsinki Finland 2013
Global Conference on Health Promotion, Shanghai China 2016

19. City Country Year Theme
Alma Ata USSR 1978 Health for All by 2000
Ottawa Canada 1986 Ottawa Charter
Adelaide Australia 1988 Building Healthy Public
Policy
Sundsvall Sweden 1991 Supportive
Environment for
Health
Jakarta Indonesia 1997 New Player for a New
Era
Mexico City Mexico 2000 Bridging the Equity
Gap
Bangkok Thailand 2005 Policy and Partnership
for Action
Nairobi Kenya 2009 Call to action
Helsinki Finland 2013 Commit Health as a
Political priority
Shanghai China 2016 Healthy Cities and
Good Governance