Health Promotion: A New Focus for Physical Education

In prophetic statements, MacDonald-Wallace (1978) stated that if physical educators do not take up the challenge, the currently developing - and published - projects in health education curricula will leave them regarded as irrelevant by educationists and public alike. Likewise, Sallis and McKenzie (1991) reiterated this thought when they stated that if physical educators do not accept a health promotion role and prepare children for a lifetime of physical activity, they will likely have diminishing influence over physical education programs in schools.

Today, we see physical education programs threatened, physical education graduation requirements eliminated, and trained physical educators being replaced by para-professionals. It is obvious that physical education has failed to demonstrate its importance to the educational community and the general public.

A recent JOPERD Four-On-One (1994) discussion asked what impact current educational reform will have on health and physical education in the next century? The overriding theme derived from the four authors of this presentation was that school based programs must have a focus on the well-being of the students. That well-being must come about by clearly defining the healthy outcomes a learner must achieve and the healthy behaviors a learner should engage. The implication in this idea is that a health promotion focus for physical education will best lead to the enhanced health and overall wellness of those involved in school-based programs with expected carry-over into adult life.

Throughout the world, physical education programs have been implementing a health-based approach. However, this focus has been limited to mostly curricula that attend to fitness and health factors affected by intense exercise alone. If physical education is to truly adopt a health oriented focus (Sallis and McKenzie, 1991), then physical educators must comprehend, and use knowledge and skills from the public health sciences. A prerequisite to this is that physical educators establish a health oriented philosophy compatible with its existing focus on skill development.

Haywood (1991) states that a public health goal means we must help students develop a knowledge base about exercise and health. Likewise, teachers must learn more about promoting positive attitudes about health and fostering appreciations for healthy living. An understanding of the theoretical constructs of health promotion and healthism within a physical education-based approach to health may contribute to the establishment of a health oriented philosophy for physical educators.

What is Health Promotion?

Health promotion is a concept that has recently gained widespread acceptance throughout the health and medical communities. It is linked to the idea of preventive medicine where we treat the potential for illness or disability before it occurs.

Health promotion has predominantly been applied to health settings throughout education, community and work environments. Health promotion is often described as a subdiscipline of health education focusing on ecological realities of health and the political dimensions of disease and health care (Tones, 1986).

Health promotion has been defined by numerous people and organizations. To fully explore the depth of meaning of health promotion, a review of several definitions seems appropriate.

The WHO (1985) states that health promotion has come to represent a unifying concept for those who recognize the need for change in the ways and conditions of living, in order to promote health. Health promotion represents a mediating strategy between people and their environments, synthesizing personal choice and societal responsibility in health to create a healthier future. Health promotion is a process of enabling people to increase control over the determinants of health.

Tones (1985, 1986) believes that health promotion should encompass any enterprise which seeks to promote health. The term health promotion has been applied to activities having a particular strategy designed to foster some aspect of health or prevent disease. These activities typically include a focus on "positive" health; developing health performance indicators based upon specified objectives; media-centered marking approaches; political advocacy to foster social and environmental change; community involvement in planning and implementing health activities; and/or a demystification of medicine (i.e. self-care techniques). Whitehead and Tones (1990) describe health promotion as any (emphasis added by authors) planned measure which promotes health or prevents disease, disability and premature death.

Healthy People 2000 (1990), the U.S. national health promotion and disease prevention objectives defines health promotion strategies as those related to individual lifestyles or personal choices that are made in a social context, and influence over one's health prospects. These strategies include physical activity and fitness, nutritition, tobacco use, alcohol and other drug use, family planning, mental health and mental disorders, and violent and abusive behavior. Educational and community programs should address these concerns in a crosscutting fashion.

O'Donnell (1992) describes health promotion as "the science and art of helping people change their lifestyle to move toward a state of optimal health." The idea of optimal health includes a balance between several personal health facets including the physical, emotional, social, spiritual and intellectual health dimensions of the individual. O'Donnell states that lifestyle change can be facilitated through a combination of efforts to enhance health awareness, change behavior toward more healthy practices, and create environments that support good health practices.

Meeks and Heit (1992) define health promotion as the informing and motivating of students to maintain and adopt healthful behaviors, participate in healthful situations, engage in healthy relationships, make responsible decisions, and effectively use resistance skills. A teacher can help students develop self responsibility for health by engaging in health promotion with: health behavior inventories, teaching strategies that promote life skills, health behavior contracts, and staying motivated incentive.

Green and Kreuter (1991) define health promotion as a "combination of educational and environmental supports for actions and conditions of living that are conducive to health." Combination refers to the necessity of matching multiple determinants of health with multiple interventions or sources of support. Educational supports are learning experiences that will facilitate voluntary actions conducive to health. Environmental supports are the dynamic social forces brought to bear on specific behaviors or one's general health.

Downie, Fyfe and Tannahill (1992) describe the goal of health promotion. In this context, health promotion is the balanced enhancement of physical, mental, and social facets of positive health coupled with the prevention of physical, mental and social ill-health.

Ewles and Simnett (1995) record that health promotion is about raising the health status of individuals and communities. Hill and Fisher (1992) state that a major goal of health promotion is to develop and maintain optimal levels of health, prevent disease and debilitating conditions, and minimize their effects if they do occur.

Baric (1991) discusses the characteristics of health promotion as involving the population as a whole (not just those at risk). It is directed toward action. It combines diverse, but contemporary, methods or approaches. Health promotion aims particularly at effective and concrete public participation. Health promotion is basically an activity in the health and social fields directed at manipulating the physical and social environment of the target population.

Ashton (1994) describes health promotion as the process of enabling people to increase control over and improve their own health. It involves the population as a whole in the context of their everyday lives, rather than focusing on people at risk for specific diseases and it is directed toward action on the determinants or causes of disease and death.

These definitions and descriptions center on four elements. Health promotion concepts seem to focus on individual lifestyles, combinations of multiple social and personal factors, raising the health levels and status of individuals, and dealing with the whole population, and not just those at risk.

To synthesise these ideas, we could describe health promotion as the process that enables choice of healthful lifestyles. One is empowered to make a personal choice to become proactive in achieving, and maintaining optimal health. This individual decision is influenced by a sense of social responsibility triggered by the interaction of dynamic forces including political action, educational programs, and media campaigns. Ultimately, the success of health promotion activities is measured by the changes in behavior within individuals or the population as a whole relative to targeted health determinants.

Healthism and Empowerment

Critics of health promotion state that programs and models aimed at improving health are too focused on individual lifestyle changes as an ultimate goal and do not address the cultural, economic and social concerns often associated with ill-health within the greater society. This association with lifestyle is believed to be a convenient construct and denotes the attempt to treat human behavior as a system within which a number of different actions take place (Baric, 1995). Often this system is not sensitive to persons or groups expectations, beliefs, preferences or skills.

This attitude is often associated with claims of "healthism" when describing the objectives of health promotion. Healthism is the preoccupation with personal health as a primary - often the primary - focus for the definition and achievement of personal well-being. Healthism treats individual behavior, attitudes and emotions as the relevant symptoms needing attention and that we as individuals control our own health existence (Crawford, 1980).

Tinning (1991) explains healthism as the tendency for health problems to be defined as essentially individual problems. The maintenance of health is a self-evident good which accepts the obvious link between physical activity and health. Personal health is essentially the responsibility of the individual with respect to lifestyle.

Colquhoun (1991) supports this concept of "self-responsibility" as a major facet of healthism. The solutions to health problems lie in the realm of individual choice .

However, Velert and Devis (1995) observed that people who do not exercise the correct (health) choices are often held responsible for their ill health. This action of "victim-blaming" parallels the concept of powerlessness. As defined by Wallerstein (1992), powerlessness is the expectancy or belief that an individual cannot determine the occurrence of outcomes.

The inverse of powerlessness is empowerment. Empowerment in it's broadest sense, is a multi-level construct that involves people assuming control and mastery over their lives in the context of their environment (Wallerstein, 1992). Empowerment and the idea of healthism have some similar perspectives. In a health sense, empowerment involves a range of competencies which provide individuals with experience of controlling their lives and their environmental circumstances (Tones, 1992). Empowerment and healthism include a conviction that you are, in fact, mostly in charge of your own life.

Baric (1995) attempts to serve as apologist for the healthism vs. health promotion discussion. He points out that most health promotion programs are shifting from focus on problems to focus on settings. They are taking a multisectoral approach, and are being more accountable for their actions.

In essence, despite conflicting ideas and criticism over healthist attitudes, any health program to promote or change the health status of a group or an individual must decide upon an agreed philosophy. Health promotion offers great scope for enhancing the quality of life of populations and individuals alike (Evans, Head, and Speller, 1994).

The concept of health promotion has largely been based in the idea that individual behavior is the prime cause of ill-health and a major factor in the maintenance and attainment of good health (RUHBC, 1995). However, new public health attitudes believe that health promotion is about social systems and collective decision making rather than being exclusively about the isolated activities of individual members of the public.

Dean (1996) points out that health promotion has evolved into a strategy for improving health which includes the physical, social, and economic environments where health and behaviour are shaped. Health promotion aims to attack the root causes of poor health by knowing about the forces that protect and damage health in daily life. This lifestyle framework understands the influence of living situations, of cultural and subgroup learning, and expectations on behavioural practice.

From an epidemiological perspective, it is the individual health factors that are largely measured. It is the individual behavior that can be most immediately affected. Without question, many social, economic and political factors influence health. Health promotion has attempted to address these issues by attempting to influence the interplay between living conditions in the wide sense and individual patterns of behavior. Through the interaction of socio-cultural factors and personal characteristics, health promotion programs seek to create a healthier pattern of behavior which is associated with improved health outcomes.

Implications for Physical Education

Physical education is in the business of health promotion. A shift in perspective, toward a health promotion focus will challenge teachers in the field to rethink and redefine their role within the educational systems of various nations.

A health promotion focus in schools has the potential to increase activity levels, improve health status, and positively affect attitudes towards physical activity (Harris,1995). Physical education can not exist solely to teach motor skills or promote sport. Although these are important aims of physical education, it must be linked to health and include within its objectives to promote physically active lifestyles through teaching individuals the skills necessary to be physically active, and imparting the knowledge to develop or change lifestyles which promote sound practices leading to optimal health.

Health promotion through physical education is the process of acquiring the necessary skills to help people (children and adults) to learn how to manage their lifestyle so they can achieve their optimal health balance. Children must come away from the primary school with a sound base in performing fundamental movement skills and possessing knowledge about practicing healthy behaviors. Young adults should leave the secondary schools having acquired lifetime sport skills and healthy behaviors which will give them the ability and interest needed to participate in movement activity and make healthy choices as an adult. Adults must maintain the skills and enthusiasm to continue to practice health promoting activities at home, and have those opportunities available in the workplace as well.

Our goal then would be to see that each individual develops skill and confidence in his or her ability to execute movement skills which is a prerequisite to realizing health benefits from activities. Programs must provide information about exercise and conditioning, healthful living, and wellness. They must foster a positive attitude toward an active lifestyle (Haywood, 1991). Physical education must do a better job of promoting its role in helping children and adults understand the value of physical activity as a determinant of health (Davis, 1996). The profession must advocate health promotion as a major objective.

Pate, Corbin, Simon-Morton, and Ross (1987) describe physical education as a modality of health promotion. Within schools, physical education should take a central role in health promotion because it encourages regular exercise as a desired health habit. Physical education is a vast existing resource whose health related origins are compatible with contemporary "preventive health" philosophy.

A physical education teacher must know how to cultivate within students and the public an understanding of achieveing health outcomes and engaging in health behaviors. To do this professional preparation and inservice programs should provide physical educators with a sound understanding of health promotion principles along with studies in health and physical education. This knowledge should go beyond sports and fitness into such areas as nutrition, drug abuse, mental health, environmental health, safety and accident prevention, and the prevention and control of disease and disorders. Kelleher (1996) adds epidemiology and public policy to this list of subjects within the study of health promotion. Hill and Fisher (1992) advocate the professional training of health promotion specialists to increase availability of these programs in schools and in the workplace.

Finally, quality physical education empowers a person to make a choice to be actively involved in physical activity. The individual decision to be physically active will only come if the person possesses the skills, knowledge, and desire to be involved. Physical education programs in schools can provide such opportunities. Successful physical education programs can not be measured by the level of achievement students attain while in school, but by the number of those participating in activity after they leave formal schooling and engaged in a health promoting lifestyle.

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