Health promotion is the process of enabling people to increase control over, and to improve, their health. It goes beyond telling people what to do: it also changes the conditions (income, housing, water, food, schools, workplaces, policies) that make healthy choices possible. Disease prevention targets a specific disease or risk factor; health promotion targets overall well-being and its determinants. The two overlap in practice.

Levels of prevention

Milestones that shaped health promotion

• Lalonde Report (Canada, 1974) — health depends on human biology, environment, lifestyle, and health care organization; it drew attention to lifestyle as a determinant.
• Alma-Ata Declaration (1978) — primary health care as the key to "Health for All."
• Ottawa Charter for Health Promotion (1986) — the first international health promotion conference. It named five action areas and three basic strategies (advocate, enable, mediate).

Ottawa Charter — five action areas

1. Build healthy public policy (for example, tobacco taxes, smoke-free laws)
2. Create supportive environments (safe walkways, clean water)
3. Strengthen community action (community participation and empowerment)
4. Develop personal skills (health education, life skills)
5. Reorient health services (from treatment toward prevention and promotion)

Health behavior theories explain why people act (or fail to act) on health advice. They help the nurse choose which factor to target: beliefs, readiness, confidence, social support, or the environment.

Health Belief Model (HBM) — an individual-level model that predicts whether a person will take a preventive action.

The action is most likely when perceived threat (susceptibility + severity) is high and benefits outweigh barriers. Reducing barriers is often the most effective nursing strategy.

Transtheoretical Model (Stages of Change; Prochaska and DiClemente)

Relapse is not a separate stage: it is a return (recycling) to an earlier stage, and it is not failure. Most people cycle through the stages several times; the nurse normalizes the lapse, identifies triggers, and helps the person re-enter at contemplation or preparation. Some versions add termination (no temptation, full confidence). Processes of change (consciousness raising, self-reevaluation, stimulus control, reinforcement) are matched to the stage.

Social Cognitive Theory (Bandura)

• Reciprocal determinism — person, behavior, and environment influence each other.
• Self-efficacy — belief in one's own ability to perform a specific behavior; one of the strongest predictors of behavior change. It is built by (1) mastery experiences (doing it successfully), (2) vicarious experience (observational learning, modeling), (3) verbal persuasion, and (4) physiological and emotional states (for example, reducing stress and anxiety).
• Outcome expectations, observational learning, reinforcement, and self-regulation are other core constructs. "Perceived barriers" belongs to the HBM, not to this theory.

Theory of Planned Behavior (Ajzen) — intention is the immediate predictor of behavior, shaped by attitude toward the behavior, subjective norms (what important others expect), and perceived behavioral control.

Pender's Health Promotion Model — a nursing model. Individual characteristics and experiences (prior behavior, personal factors) affect behavior-specific cognitions (perceived benefits, barriers, self-efficacy, activity-related affect, interpersonal and situational influences), leading to commitment to a plan of action and the health-promoting behavior. Unlike the HBM, it does not rely on fear or threat.

Social ecological model — behavior is shaped at several levels: individual (knowledge, skills), interpersonal (family, peers), organizational (schools, workplaces), community (norms, physical environment), and public policy (laws, taxes). Multilevel programs work best. Building parks and safe walkways is a community-level strategy; a school canteen policy is organizational; a tax on sweetened drinks is policy.

PRECEDE-PROCEED model (Green and Kreuter) — a planning and evaluation framework.

• PRECEDE (assessment and planning): (1) social assessment (quality of life), (2) epidemiological assessment (health problem, plus behavioral and environmental factors), (3) educational and ecological assessment of predisposing (knowledge, attitudes, beliefs, values), enabling (availability, accessibility, cost, skills), and reinforcing factors (support, feedback, rewards from family, peers, health workers), (4) administrative and policy assessment.
• PROCEED (implementation and evaluation): implementation, process evaluation, impact evaluation (short-term change in the factors and behaviors), outcome evaluation (health status and quality of life).
• Older editions number these as nine phases (behavioral/environmental and educational diagnoses as separate phases); the order of the assessments is the same.

1. Assess the community's priority problems and the behaviors behind them (community diagnosis, FHSIS data, surveys).
2. Choose a theory that fits the target:
   • An individual deciding whether to be screened → HBM
   • A smoker's readiness to quit → Transtheoretical Model
   • Low confidence to do a skill (insulin injection, breastfeeding positioning) → Social Cognitive Theory (self-efficacy)
   • Behavior shaped by the environment and norms → social ecological model
   • Planning a whole program with evaluation → PRECEDE-PROCEED
3. Match strategies to levels: individual counseling and skills, family and peer support groups, school and workplace programs, barangay ordinances and environmental changes.
4. Build self-efficacy: demonstrations with return demonstration, success stories from local role models (a former smoker, a mother who breastfed exclusively), small achievable goals.
5. Reduce barriers: bring services closer (barangay health stations, mobile clinics), adjust schedules, use free services.
6. Evaluate at process, impact, and outcome levels.

Philippine program link. The Universal Health Care Act (RA 11223, 2019) directs the Department of Health (DOH) to scale up health promotion and preventive care and to turn its health promotion and communication office into a Health Promotion Bureau that improves health literacy. Local government units (LGUs) carry out health promotion through rural health units and barangay health stations, with barangay health workers (BHWs) as front-line partners.

• Educator — gives accurate, understandable information adapted to literacy and language (Filipino, English, or the local language).
• Counselor and motivator — assesses readiness, uses motivational interviewing, supports self-efficacy.
• Advocate — speaks for policies and environments that support health (smoke-free areas, safe water, healthy school food).
• Community organizer and collaborator — works with barangay officials, BHWs, schools, churches, and workplaces; builds community participation.
• Role model — practices the behaviors she promotes.
• Researcher and evaluator — measures whether programs change behavior and health.

• Autonomy — promote informed choice; persuasion is ethical, coercion is not. Fear appeals should be accurate and paired with a clear, doable action.
• Beneficence and justice — prioritize groups with the greatest need (geographically isolated and disadvantaged areas, the poor, indigenous peoples); avoid programs that widen inequity.
• Truthfulness — do not overstate risks or benefits.
• Confidentiality and data privacy — personal health information collected in surveys and screening is protected under the Data Privacy Act of 2012 (RA 10173); collect only what is needed and store it securely.
• Cultural respect — respect beliefs and practices while correcting harmful ones gently; involve community leaders.
• Documentation and accountability — record activities, attendance, and results accurately; nurses remain accountable to their professional code of ethics.

Case 1. A 48-year-old woman with a family history of breast cancer says, "It will not happen to me," and has never been screened.

• Action: raise perceived susceptibility by explaining her personal risk, then lower barriers (schedule, cost, location) and give a cue to action (appointment and reminder).
• Why: HBM — low perceived susceptibility is the main obstacle here.

Case 2. A jeepney driver says he wants to stop smoking "sometime next year, maybe," and lists reasons for and against.

• Action: he is in contemplation. Explore ambivalence and highlight benefits; do not push a quit date yet.
• Why: strategies must match the stage; action-oriented tactics in contemplation increase resistance.

Case 3. A mother knows exclusive breastfeeding is best but stops because she "cannot do it right."

• Action: hands-on positioning and latch practice with return demonstration, a peer breastfeeding supporter, praise for each success.
• Why: low self-efficacy; mastery and vicarious experience build it.

Case 4. Adults in a barangay rarely exercise; there are no safe walkways.

• Action: partner with the barangay council for lighting and walkways, group exercise sessions, and an ordinance for car-free hours.
• Why: social ecological model — community and policy levels.

• Confusing theories: perceived barriers = HBM; self-efficacy and observational learning = Social Cognitive Theory; stages = Transtheoretical Model; predisposing, enabling, reinforcing = PRECEDE.
• Calling relapse a "failure" — it is an expected part of change.
• Mixing up contemplation (within 6 months) and preparation (within 1 month).
• Enabling vs. reinforcing: enabling = resources, access, skills, cost (makes the behavior possible); reinforcing = rewards and support from others after the behavior (keeps it going). Knowledge and beliefs are predisposing.
• Relying only on information-giving; knowledge alone rarely changes behavior.
• Using fear without giving a practical action — it may produce denial.
• Forgetting that health promotion includes policy and environment, not only teaching.

• Ottawa Charter (1986): five action areas — healthy public policy, supportive environments, community action, personal skills, reorienting health services; strategies advocate, enable, mediate.
• HBM: susceptibility, severity, benefits, barriers, cues to action, self-efficacy; raise susceptibility to increase screening.
• Stages of change: precontemplation (no intent in 6 months), contemplation (within 6 months), preparation (within 1 month), action (under 6 months), maintenance (6 months or more); relapse = recycling to an earlier stage, not a separate stage.
• Social Cognitive Theory: reciprocal determinism, self-efficacy, observational learning, outcome expectations.
• Self-efficacy is built by mastery, modeling, persuasion, and physiological and emotional states — mastery is strongest.
• Theory of Planned Behavior: attitude + subjective norm + perceived behavioral control → intention → behavior.
• Pender's model is a nursing model focused on health-promoting behavior, not fear of disease.
• Social ecological model: individual, interpersonal, organizational, community, policy; parks and walkways = community level.
• PRECEDE factors: predisposing (knowledge, beliefs), enabling (access, resources, skills), reinforcing (support, rewards).
• PROCEED evaluation: process → impact (factors and behavior) → outcome (health status, quality of life).
• RA 11223 created the DOH Health Promotion Bureau to improve health literacy.