Beattie’s model of health promotion is a complex analytical model that acknowledges that health promotion is ‘embedded in wider social and cultural practices’ (Wills and Earle 2007, Chapter 5) This model not only gives us the ability to analyse current and previous health promotion strategies and our own roles within that, but also gives us the resource to build upon current practice and to generate new strategies for successful health promotion (Wills and Earle 2007, Chapter 5).
Beattie’s model consists of four quadrants, arranged on two axes. The four quadrants represent the different ways in which health can be promoted by professionals, governments, and individuals, through health persuasion techniques, legislative action, personal counselling and community development. The two axes represent ‘mode of intervention’ which can be authoritative (a top down approach) or negotiated (a bottom up approach) and ‘focus of intervention’ which can be individual or collective (Thomas and Stewart 2005; Naidoo and Wills 2007, Chapter 5; Wills and Earle 2007, Chapter 5).
Governments and health care professionals typically work in a ‘top down’ approach, through legislative action and health persuasion techniques. Here, advice and recommendations are handed out, and policies and interventions designed to increase uptake of these recommendations are established. The aim of this is to protect individuals and communities. However, both of these approaches on their own may disempower individuals through a ‘victim blaming’ culture and may therefore result in only limited change (Thomas and Stewart 2005).
The personal counselling approach and the community development approach both seek to empower and to enhance knowledge, understanding, and skills. With the personal counselling approach, this is achieved through a health professional assisting the individual to develop and reach their goals, rather than acting as an expert instructing them how to change. The community development approach is similar to this, except that rather than focusing on individuals, the focus is on groups, such as local community groups (Naidoo and Wills 2007, Chapter 5). Community development does require an ‘enabler’ or facilitator who will help to drive the project, but the risk then is whether this facilitator brings their own agenda to the project, thereby diverting resources towards their own objectives rather than those of the community at large (Thomas and Stewart 2005).
I have previously worked as a medical writer working with pharmaceutical companies in marketing medicines to health professionals. This fits best in the health persuasion quadrant of the model, representing an authoritative, or top down approach. However, I should note that as this work was directed at health professionals rather than at patients themselves, it may not be seen exactly as ‘health promotion’. For example, when promoting an antihypertensive drug, the messages are directed at health professionals, in terms of educating them about the risks of elevated blood pressure such as increased risk of cardiovascular events and stroke and the existence of treatment guidelines that recommend that blood pressure should be reduced to at least 140/90 mmHg in all individuals and lower in ‘at-risk’ populations. These messages are most often delivered by senior, expert physicians – so called ‘key opinion leaders’ who take the ‘top down’ approach to less experienced doctors, or general practitioners with less specialised knowledge.
Of course the messages about blood pressure are taken up by other groups and in other formats which fall into other areas of Beattie’s model. For example, there are NHS framework targets for doctors to reduce blood pressure across a range of patients, which would fall into the legislative action quadrant. My work was indirectly linked to this quadrant, as I worked mainly with the key opinion leaders who formulate blood pressure guidelines (for example, for the European Society of Hypertension and British Hypertension Society) and it is these guidelines that feed into the framework targets and NICE guidelines. In addition, personal counselling approaches through, for example, Patients Advice and Liaison Service (PALS) and community development approaches coming from groups such as the Blood Pressure Association.
Some authors suggest that contemporary health promotion should not focus exclusively on any one single element, such as disease prevention, or societal change (Tannahill 2008). Here, the author sees health promotion as being made up of socio-economic, physical and environmental factors, education and learning, services and amenities, and community activities (Tannahill 2008). Beattie’s model supports this notion, by allowing us to analyse the complexities of health promotion approaches and by demonstrating that many agencies with many different approaches across all quadrants and axes are needed for well-rounded health promotion policies and practice.
There are several theories surrounding health behaviour, and many factors which act both as determinants of and barriers to change. Individuals rely on many different factors when thinking about their health, such as their basic health knowledge, their level of motivation, general attitudes and beliefs and their self-concept (Wills and Earle 2007, Chapter 5). The different behaviour change models take in to account these factors to greater or lesser extents.
My personal opinion is that of the main models of health, the health action model represents the most satisfactory behaviour change model. This model examines why individuals act in ways that can appear irrational to others, for example through drug use or smoking, despite being aware of the health risks.
The health action model is built around three systems: the motivation system, the belief system and the normative system (Tones 1987; Wills and Earle 2007, Chapter 5). The belief system is similar to that used in the health belief model, which states that individuals will change to protect their health based upon four circumstances: their likely susceptibility to a disease or illness, the potential severity of that illness, the existence of beneficial measures and the potential barriers to taking action (Wills and Earle 2007, Chapter 5). The health belief model assumes that all individuals make decisions in a rational manner, by weighing up the pros and cons before acting in the most reasonable manner. However, this may oversimplify the decision making process by not taking into account other ‘irrational’ factors that affect the way individuals consider their health. For example, an individual who continues to engage in risky sexual behaviours despite knowing the health risks, thereby sacrificing long-term health for short-term pleasure.
The normative system of the health action model represents outside influences on an individual, such as peer group influences, and acknowledges that social policy may play a role in health behaviours. For example, the social policy banning smoking in public places influences how ‘normal’ this activity appears, and may therefore affect the prevalence of smoking (Tones 1987). It offers the beginning of an explanation for some of the seemingly irrational health behaviours people exhibit by showing how outside influences may affect behaviour. The transtheoretical model of health would simply state that this individual is ‘not ready’ or at the correct stage to make a change. Again, however, I feel that this oversimplifies the problem, and also adds to health inequalities by apportioning blame to the individual.
The motivation system of the health action model consists of an individual’s values attitudes and drives (Tones 1987). Influences from the belief system and the normative system feed into the motivation system and also affect health behaviours and health outcomes (Tones 1987).
Feeding in to all three of these systems are the ideas of self-esteem and self-concept, where how empowered an individual feels, where their ‘focus of control’ lies and an individual’s ‘self-efficacy’ all play a part in their health behaviours (Tones 1987). Tones offers the example of an individual who wishes to cut down on their social drinking, but their ‘normal’ social setting gives rise to peer pressure to act in the same manner as ever (Tones 1987). In this example he states that while an individual may feel assertive, with a high self-esteem, if their experiences within the group run counter to their expectations (e.g. if they are criticised rather than praised for their actions) this can affect future health behaviours and attitudes (Tones 1987).
The health action model therefore takes into consideration some of the complexities of every day life, and the external influences which people often feel they have no control over (Tones 1987; Wills and Earle 2007, Chapter 5). In my opinion this is an advantage over the transtheoretical model of health, which focus on the individual and whether or not they are ‘ready’ or at the correct stage to make a change, regardless of the external influences that may be holding them back. Such focus on the individual may be seen as blame and may lead to additional health inequalities.
It is clear that devising activities that effectively change behaviour is a difficult task and to this end NICE have published guidelines relating to health behaviour interventions. These guidelines stress the importance of working in partnerships, taking into account social context and developing programmes that work to help communities and individuals feel positive, set goals and to build resilience and key skills. These guidelines draw on evidence from a number of models, and I believe that it is the wide range of influences that will result in the most effective programmes (NICE 2007).
Wills, J. and Earle, S. (2007). Theoretical perspectives on promoting public health. in Theory and research in promoting public health. Earle, S., Lloyd, C. E., Sidell, M. and Spurr, S., Sage, London / The Open University, Milton Keynes.
Thomas, S. and Stewart, J. (2005). Optimising health promotion activities. Journal of Community Nursing 19(1): 9-12.
Naidoo, J. and Wills, J. (2007). Models and approaches to health promotion. in Health promotion: Foundations for practice. Naidoo, J. and Wills, J., Bailliere Tindall / Royal College of Nursing.
Tannahill, A. (2008). Health promotion: The Tannahill model revisited. Public Health 122: 1387-1391.
Tones, K. (1987). Devising strategies for preventing drug misuse: the role of the Health Action Model Health Education Research 2(4): 305-317.
NICE (2007). NICE public health guidance 6: Behaviour change at population, community and individual level www.nice.org.uk/PH006