An Ecological Perspective on Health Promotion Systems, Settings and Social Processes

The chapter presents the aims of the book, describing what health promotion is, why it is needed, who is doing it, where it is done and how it is done.

The chapter starts with an overview over the major public health concerns in developed countries, in particular the prevalence and trends in lifestyle related diseases such as cardio-vascular disease and cancer, and in mental health problems such as depression, as well as positive indicators of health and quality of life. The history of health promotion as an ideology and strategy to address these public health issues is presented, including the main message from the very first charter of health promotion from a conference in Ottawa in 1986. Furthermore, the role of health promotion in Scandinavian welfare states is discussed.

The chapter argues that there is a need for an ecological approach to health promotion, which calls for a multidisciplinary approach, acknowledging the importance of macro-level and micro-level conditions. In this book, the ecological systems approach is applied to various public health areas such as family welfare, well-being in school, subjective health and health behaviours among adolescents, and public policy. In the introductory chapter, the connection between the various chapters is explained, with a focus on how the chapters illustrate the social processes and systems involved in health promotion.

In this chapter arguments are given to avoid overly-simple views of what causes good and ill health, based on simple associations between proximal risk factors and health status. The author discusses the importance of causal processes to understand why two variables are associated and what this association means; what are the mechanisms of the association, and what other key factors may operate in presumptively causal relationships? It is suggested that an ecological view of health is preferable, with attention to biopsychosocial processes from the micro to the macro levels. Further, it is argued that the role that the physical and social environment plays in determining the public’s health is of particular importance to health promoters. This calls for research models that embrace intra-personal, psychosocial and social/cultural processes. Building on the Ottawa principles for health promotion the chapter introduces a model for a whole community approach to health improvement. The model shows how the multi-level processes in community settings and at different system levels shape health. Further, the model makes it clear that understanding these processes are beyond the interests and expertise of any one health discipline and therefore inter-disciplinary approaches are needed.

This chapter provides a historical overview of health behaviour research and takes a critical stand towards that most theory-based research on health behaviours is based on social cognition models, focussing mainly on personal factors and perceived aspects of the social environment. The chapter argues that social processes in different settings and at different systems levels must be taken into account by addressing larger social, physical, organisational, cultural and societal contexts when aiming at explaining health behaviours.

A conceptual model describing these contextual factors is presented. The model represents a way to systematize domains or systems of factors (personal, micro and macro level factors) believed to be important when analyzing the widest possible range of external influences on health behaviours. For each contextual factor the mediating or moderating role it may have on the health behaviour outcome is examined by using theory and empirical research findings.

This chapter addresses system-level analyses by discussing the translation of Norwegian national health promotion policy into municipality-level actions, with a focus on implementation conditions. In the 1990s, several nationwide health promotion programmes were initiated that aimed at integrating health promotion work into the social welfare and health agendas of municipalities. Two of these programmes are analysed in this chapter. The analyses combine two different perspectives: a decision perspective that studies the project outcomes in terms of how the projects were integrated into local government, and a process perspective that focuses on how the participants worked together and on their experiences of working on the projects. The analyses found that projects aimed at integration with local government administration were more successful than projects that aimed at empowering local communities. It seems that a system-level approach is more effective than a community approach. This finding represents a dilemma for health promotion that aims to stimulate community-setting approaches and involve local residents. Consequences of the observed dilemma are discussed.

This chapter describes how family welfare is considered a public responsibility in the Scandinavian countries, in contrast to the USA and UK where emphasis is placed upon private provision. The role of the national authorities encompasses two main processes: placing relationships on the political agenda, and funding the development and implementation of various measures. Two main approaches to relationship education are addressed: 1) a more direct approach of identifying risk factors for developing relation problems and conflicts, as well as protective factors strengthening relationship bonds and enhancing the quality of the couple relationship, and 2) a less direct approach of evaluating specific programmes through participant evaluations and various types of experimental designs. The latter is exemplified by the Prevention and Relationship Enhancement Program (PREP) considered the most scientifically rigorous relationship education programme. PREP is based on a cognitive–behavioural theoretical framework and is designed to provide couples with knowledge, communication, and problem-solving skills associated with effective relationship management. The chapter includes a discussion of the theoretical and empirical demarcation between relationship education and couples therapy. It emphasizes that couples seeking help for their relationship difficulties may not benefit from relationship education.

This chapter discusses the relationship between students’ experiences in school and their health and life satisfaction, with particular emphasis on how social processes within the school setting play a significant role in this relationship. Building on data from a large international survey, the chapter aims to demonstrate how students’ overall life satisfaction is associated with health promotion processes in schools. By utilizing motivation-based theories such as self-determination theory and goal achievement theory, attention is focused on explaining the relevance to student life satisfaction of processes that stimulate: 1) student empowerment through autonomy and participation; 2) their relatedness to peers and teachers; and 3) learning processes through which students experience mastery. Further examples of how such processes can be stimulated are provided from the Norwegian and the European Network of Health Promoting Schools. This chapter demonstrates that a school environment that does not stimulate health promotion processes is more likely to be perceived as stressful by the students. Exploring the school environment from a stress perspective verifies how high demands and student role strain in combination with low empowerment may result in higher levels of subjective health complaints and ill health.

This chapter reviews the prevalence of depressive tendencies among adolescents, discusses individual and social risk factors and concludes by making a number of recommendations on how to promote positive mental health among adolescents. Significant individual processes related to pubertal development, vulnerability (in particular low self-esteem and negative body image) and identity confusion are discussed as significant individual processes that impact on the experience of depressive tendencies among adolescents. Significant social processes are also identified, including social support from parents, peers and others, type of relationship with parents, quality of friendships and bullying. The chapter discusses how stressful events may cause depression depending on the way the young person copes with the stress, as well the extent to which he or she is vulnerable and receives adequate social support. Girls are more at risk for developing depressive tendencies, and possible reasons for the gender differences are presented. This chapter discusses health promotion among adolescents in terms of increasing their control and improving how they cope with events that may compromise their life satisfaction and vitality. The main focus is on how to increase the possibilities for young people to meet successfully life challenges by improving their social competence, self-esteem and coping abilities, and strengthening social networks. A number of recommendations on how to promote mental health and prevent depressive tendencies among adolescents are suggested. These include programmes and interventions targeting the family, school, health services and public programmes at different societal levels.

This chapter presents the family, school and leisure activities as the main settings for adolescent development and discusses the influences of social processes on health behaviours in these settings. The main processes are described through the social psychological constructs of social norms and social support, and observational learning, an approach informed by social cognitive theory, one of the most influential theories used in health promotion. The chapter discusses legislation and international conventions as more formalized norms. The role of such norms in promoting healthy behaviours among adolescents is demonstrated by findings from an international study on the effect of national legislation on smoking in schools. The influences of these social processes in the main developmental settings for adolescent health behaviour are analysed in terms of systems theory, particularly ecological systems theory, and the reproduction of social inequality.

In this chapter, the macrosystem-level influence on health promotion developments in Norway is analysed by demonstrating how the development of the Norwegian welfare state, initiated before World War II, has been influenced by shifting political foci and priorities. The development of the welfare state has been largely a political matter guided by left wing governments with high priorities on improving structural conditions and securing healthy living conditions in work-places, housing, education and access to health services. Similarly, development of the Norwegian Health Promotion Policy over the last two decades has been influenced by varying levels of politicalization.

Under left wing governments, health policies were developed as opposed to policies primarily focused on prevention of disease; there was also an increase in local autonomy in implementation of national health policy and a focus on equity in health. In all these change processes, emphasis was given to how public health could be improved through the governing system from national to local implementation and by involvement of an increasing number of sectors. During the periods when right wing governments were in power, more emphasis was given to individual responsibility for health and health policy declined in political importance. This pendulum swing in the politicalization of health policies is analysed through White Papers and action plans. It traces how Norwegian governments have acted upon the international health promotion movement initiated at the Alma Ata conference and through the Ottawa Health Promotion Charter. Similar pendulum swings are also found in other Western countries.

The final chapter brings together the contributions from all chapters, highlighting how effective health promotion depends on reaching the settings in which people live, and understanding the processes of human interaction in these settings. The chapter starts with an analysis of how international conventions and agreements about health actions (such as those mentioned in chapter 5 and 7) may influence national policies, and how these are implemented in settings at local levels as discussed in chapters 3, 4, 6 and 7. The chapter goes on to analyse how implementation of such actions at national and international level influences the significant social processes in these settings, and why this influence may result in positive changes in health behaviour and health. The chapter concludes with a discussion of how systems theory may help to understand how social processes and settings at different societal levels are linked, proposing an ecological systems model of health promotion including all five principles of health promotion action as outlined in the Ottawa Health Promotion Charter.