Health Promotion in Primary Care

Health’ Defined

Merriam-Webster Dictionary defines ‘Health’ as the condition of being good in body, mind, or spirit that is particularly free from physical disease or pain.

Definition of Health Promotion

In its simplest form, the word “health” means the absence of disease. This well-known definition was expanded in the 1970s and 1980s, as other features were included namely intellectual, environmental, and spiritual health. The balance of all these components is based on the principle of self-responsibility.

Michael O’Donnell, the editor of the American Journal of Health Promotion, defines health promotion as the following: “It is any combination of health education, and related organizational, political, and economic intervention designed to facilitate behavioral and environmental changes conducive to health.” This definition emphasizes the interdisciplinary nature of health promotion. Any actions or conditions of living beneficial to health are part of the wide field of health promotion. The following is a sample of health promotion sub-categories:

  • Physical fitness
  • Smoking control
  • Mind-body health
  • Spiritual health
  • Medical self-care
  • Environmental health
  • Employee assistance programs
  • Nutrition
  • Stress management
  • Social health
  • Weight management
  • Work safety
  • Prenatal care

Disease prevention focuses on protecting as many people as possible from the detrimental impacts of a threat to health. Health promotion includes the development of lifestyle habits, which healthy individuals and communities can take up to maintain and improve the state of health. The critical goal is the optimization of health.

Definition of Community Development

Community Development is more significant than economic development. It is the process or effort of building communities on a local level with a focus on building the economy, forging and strengthening social ties, and developing the non-profit sector. It is applied to the practices and academic disciplines of civic leaders, activists, involved citizens, and professionals to improve different aspects of local communities.

Community development helps a community reinforce itself and develop towards its full potential. As facilitators, we work in partnership with local people and organizations to meet identified needs.

Definition of Health Education

It is defined as the process by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, or restoration of health.

Education for health begins with the people, as they are, with whatever interests they may have in improving their living conditions. It aims to develop in people a sense of responsibility for health conditions, as individuals and as members of families and communities.

Primary Health Care Defined

Primary health care focuses on the provision of medical services treating individual, usually delicate medical conditions. It forms only a part of comprehensive primary health care, which is the broader, holistic approach to health problems. In addition to primary medical care, comprehensive primary health care deals with a range of health concerns that have no precise medical intervention.

Primary health care is based on practical, scientifically sound, culturally suitable, and socially acceptable methods. It is commonly accessible to people in their communities, involves community participation, is vital to, and a central function of, the health system, and is the first level of contact with the health system.

The Determinants of Health

Hay and Wachtel (1998) point that the list of determinants is not fixed and “depends on the perspective of the persons or groups defining the particular population health model” (p. 10). The Federal, Provincial and Territorial Advisory Committee on Population Health (1994) for instance, decided upon nine determinants of health. These included: income and social status, social support networks, education, employment and working conditions, physical environments, biology and genetic endowment, personal health practices and coping skills, and healthy child development and health services (p. 2-3).

Health promotion philosophy has developed, and continues to change, in due course. It has moved from the pre-1970s view of health being the absence of disease through to the population health model of the 1990s. As stated by the advisory committee, “Population health has as its goal the best possible health status for the entire population. In contrast, health care has as its aim the treatment or rehabilitation of illness” (The Federal, provincial and Territorial Advisory Committee on Population Health 1994, p. 10).

This development has led to a modern emphasis on the broad determinants of health and moves beyond the medical and behavioral approaches to embrace social, economic, and ecological factors. The determinants of health are exemplified in the Ottawa Charter for Health Promotion. They are characterized by a philosophy in which, “Empowerment, or the capacity to define, analyze and act upon one’s life and living conditions, joins treatment and prevention as important health professional and health agency goals” (Labonte 1993).

Health Promotion: An Analysis

Health promotion is “the process of enabling people to increase control over and to improve their health” (WHO, 1986). Later definitions advocate strategies by which the goals of health promotion may be achieved. “Health promotion is the combination of educational and environmental supports for actions and conditions of living conducive to health” (Green & Kreuter 1991, 1999).

The field of health promotion has undergone a process of advancement that is relevant to the discussion of the role of health promotion in primary care. This advancement can be explained in several fairly distinct periods. In the public health period of the early twentieth century, the primary health concerns related to the treatment of communicable diseases and ensuring the provision of clean water and food. The next period involved the entrenching of the ‘medical model’ as the dominant paradigm in public health.

In the 60s and 70s, there was a move toward greater importance on behavioral health education and social marketing. The Lalonde Report introduced the ‘health field’ theory and sought to break health policy “into manageable units” (LaFramboise 1973). Four main categories were recommended: lifestyle, biology, health care, and the environment. The Lalonde report embarked on documents and frameworks, however led to little firm shift in health resources and no rational policy approach.

In due course, the standpoint of the Lalonde report shifted towards combined stress on health promotion as self-responsibility, notions of community empowerment, and healthy public policy (Epp 1986; WHO 1986). Health promotion has been contested by the population health approach, which highlights the role of the broad determinants of health.

In discussing the role of health promotion in primary care, it should be seen that the roots of population health are compatible with and in many ways offshoots of, influential documents in health promotion. The Ottawa Charter highlighted the role of healthy public policy and creating helpful environments. The Charter placed health not as an end in itself but as a “resource for living” (WHO, 1986). Primary care should be placed as part of a general strategy for health promotion, disease prevention, and population health.

The Epp Framework (Achieving Health for All) laid the stress on the importance of removing or reducing health imbalances. Healthy public policy was a crucial element of the Ottawa Charter and supporters of health promotion identified government with “explicit concern should enact that healthy public policy for health and equity, and accountability for health impact” (Hancock, 1988). From a health promotion viewpoint, healthy public policy “creates and encourages a context for health” (Rachlis & Kushner 1989). In the context of primary care, healthy public policy must also enable and continue the conditions for health promotion, disease prevention, and population health.

The notion of health promotion has taken on a distinct flavor that is relevant to the discussion of health promotion in primary care. There is a strong social, community, and self-reliance element. The overall model of health promotion is centered on the concepts of self-help, mutual aid, and citizen participation.

Academic representations of health normally go beyond a narrow definition of health to include both real and personal components, both humanistic and statistical aspects, and individual in addition to environmental and policy components, and both qualitative and quantitative research approaches. The health concept in health promotion has a non-medical tenor, in that the biological component of health is not important. Nevertheless, when it comes to seeking resources the general meaning of health promotion tends to be preventive rather than wellness-oriented. Health as believed in the context of health promotion has to do with the bodily, mental, and social quality of life of people as determined in particular by psychological, societal, cultural, and policy dimensions. Health is seen by health promoters to be improved by the sensible standard of living and the fair use of public and private resources to allow people to use their programs individually and collectively to maintain and improve their welfare.

Health promotion has a strong cultural and equity aspect and recognizes the contribution of various groups and communities that make up a country. There is a strong inherent factor of empowerment in health promotion and efforts have focused on high priority sectors such as youth, women, and the disabled populations.

A set of values and principles has come to be related to health promotion practice, policy, and research. Health promotion is a collective approach. It examines the power of economic rationalism in public policy and discards professional governance in health promotion practice. Health promotion recognizes that power is central to practice and embraces a power-with against a power-over approach. Health promotion is concerned with a vision of an ideal future. This vision includes ‘a viable natural environment, a sustainable economic environment, a sufficient economy, an equitable social environment, a convivial community and a livable built environment’ (Labonte 1993).

It is agreed with Birse (1998) and colleagues that in a primary care context there are three corresponding approaches to promoting health. Each of these approaches is considered in the discussion of criteria for health promotion in primary care settings. They include the medical approach, the lifestyle/behavioral approach, and the socio-environmental approach.

Health Promotion in Primary Care Settings

The scientific literature provides considerable support as to the potential effectiveness of health promotion in primary care settings. The assessment of the literature produces several review articles in this area on a diverse range of topics.

If one takes the instance of heart disease, it is clear that health promotion in primary care can reduce mortality and morbidity, psychological misery, and some biological risk factors. Ebrahim and Smith (1998) performed a methodical assessment and meta-analysis of randomized controlled trials to estimate the effects of different non-pharmacological interventions on blood pressure. Improvements in systolic blood pressures were observed in the following intervention groups: salt restriction, weight loss, stress control, and exercise. Likewise, Linden et al. (1996) pointed out that the addition of psychosocial interventions improves the result of standard rehabilitation treatment for patients with coronary artery disease. Psychosocially treated patients showed greater reductions in psychological distress, systolic blood pressure, heart rate, and cholesterol level. Patients who did not receive psychosocial treatment showed greater mortality and cardiac recurrence rates during the first two years of follow-up. Brunner et al. (1997) assessed the efficacy of dietary advice in the primary prevention of chronic disease. They found that individual dietary interventions in primary prevention could achieve improvements in diet and cardiovascular disease risk conditions that are maintained for nine to 18 months.

The usefulness of health promotion in primary care is not limited to heart disease. For instance, Mandelblatt and Yabroff (1999) studied the usefulness of interventions targeted at providers to improve the use of mammography. Interventions were graded as behavioral, cognitive, or sociological and further categorized the type of control group. Behavioral interventions increased screening by 13.2% as compared with usual care and by 6.8% as compared with active controls. Cognitive intervention strategies improved mammography rates by 18.6%. Sociological interventions had a similar magnitude of effect on screening rates.

A common strategy for health promotion is health education. Birse et al. (1998) quote several papers to show that health education approaches are a useful means of changing knowledge, outlooks, and to some extent health behaviors. They also mention evidence that the success of health education can be improved through the use of personal skills development, use of rewards or incentives, and multifaceted interventions. Second, Birse et al. (1998) maintain that social marketing and health communication strategies are a useful component of a wide-ranging health promotion strategy. Third, there is rather a strong indication for the efficiency of brief interventions in clinical environments. These include areas such as injury prevention, physical activity, nutrition, smoking cessation, and problem drinking. Birse et al. (1998) assume that health promotion in primary care should be increased by careful use of self-help, self-care, and mutual aid strategies and supported by healthy public policy and community development.


Birse, E & with the Working Group on Integrated Health Systems, Centre for Health Promotion, 1988, The role of health promotion within integrated health systems.

Brunner, E White I, Thorogood M, Bristow A & Curle D, et al. 1997, Can dietary interventions change diet and cardiovascular risk factors? A meta-analysis of randomized controlled trials. Am J Public Health, 87: 1415–1422.

Ebrahim, S & Davey-Smith G 1998, Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions, Journal of Public Health Medicine, 20:441–8.

Epp, J 1986, Achieving health for all: A framework for health promotion, Ottawa, ON: Health and Welfare Canada.

Federal, Provincial and Territorial Advisory Committee on Population Health 1994, Strategies for population health: investing in the health of Canadians, Publications Health Canada, Ottawa, Ont.

Green, L & Kreuter M 1991, Health Promotion Planning: An Educational and Environmental Approach, Mayfield, Mountain View, CA.

Hancock T 1988, Developing healthy public policy at the local level, In Evers A (ed) Health Public Policy at the Local Level: European Centre for Social Welfare Policy and Research, Westview Press, Colorada.

Hay, D Wachtel, A 1998, The well-being of British Columbia’s youth and children: A framework for understanding and action, Vancouver, BC: First Call.

Labonte, R 1993, Health promotion and empowerment: practice frameworks, Centre for Health Promotion, University of Toronto. Issue #3, 1-92.

Laframboise, HL 1973, Health policy: Breaking the problem down into more manageable segments, Canadian Medical Association Journal, 108, 388-393.

Lalonde, 1974 The Lalonde Report: A New Perspective on the Health of Canadians.

Linden, W, Stossel, C, & Maurice, J 1996, Psychosocial interventions for patients with coronary artery disease. Archives of Internal Medicine, 156, 745-752.

Mandelblatt JS & Yabroff KR. 1999, “Effectiveness of Interventions Designed to Increase Mammography Use: A Meta Analysis of Provider-Targeted Strategies” Cancer Epidemiology, Biomarkers and Prevention, 8(9): 759–67.

O’Donnell, M 1989, American Journal of Health Promotion, 1989, 3, 3, 5.

Rachlis, M & Kushner, C 1989, Second Opinion: What’s Wrong with Canada’s Health Care System and How to Fix it, Toronto.

World Health organization 1986, Ottawa Charter for Health Promotion.