W1: Introduction to Health Promotion
Literature
Huber, M., Knottnerus, J. A., Green, L., Van Der Horst, H., Jadad, A. R., Kromhout, D., & Smid, H (2011). How
should we define health?
WHO (1964) → health = a state of complete physical, mental and social well-being and not merely the absence of
disease of infirmity
At that time, this was revolutionary, broadening the idea of health beyond disease absence to include well-
being in multiple dimensions.
However, despite its influence, the definition has not been revised since 1948, even as global demographics
and disease patterns have evolved.
Increasing criticism suggests the definition is now outdated and counterproductive.
Limitations of the WHO definition:
Defining health as complete well-being is unrealistic and harmful
Changing disease patterns → when WHO issued the definition in 1948, acute diseases were dominant and
often fatal; today chronic diseases account for most morbidity and healthcare costs globally
The definition’s reliance on a “complete state” of health makes it impossible to operationalize or measure
effectively
Current health policy, research and clinical practice → rely on definitions that determine what is measured as
health gain
E.g., societal participation or coping capacity may be more relevant outcomes than full recovery for people
with chronic diseases
Ottawa Charter for Health Promotion (1986) = addressed social and personal resources and physical
capability
WHO never adopted this formally
Huber (2011) → health = the ability to adapt and to self-manage in the face of social, physical and emotional
challenges
Shifts health from a static state to a resilience-based process, integrating biological, psychological and social
adaption
Reflects dynamic understanding of health; emphasizing resilience, personal autonomy, and social
participation rather than unattainable perfection
Health can de defined across three domains:
Physical health = reflects an organism’s ability to respond, recover and maintain equilibrium under stress
Allostasis = the ability to preserve stability through change
Allostatic load = failure of allostasis; resulting in tissue damage and disease
Mental health = involved adapting coping and the maintenance of meaningful engagement with life
Sense of coherence = the mental capacity to find meaning, manageability, and comprehensibility in
stressful experiences
Social health = the ability to participate in society, fulfill roles, and maintain independence despite illness
W1: Introduction to Health Promotion 1
, Disability paradox = people can perceive high quality of life despite significant disability if they adapt
successfully
Stanford chronic disease self-management program → patient who learned self-management techniques
reported:
Improved self-rated health
Less fatigue and distress
Greater energy and social participation
Lower healthcare costs
Clark & Janevic (2014), Individual theories. The Handbook of Health Behavior Change
Individual adherence = whether people actually follow through on recommended behaviors such as taking
medications, keeping appointments, and making lifestyle changes
Non-adherence remains a major barrier to achieving positive health outcomes
Poor adherence is common whenever patients must take discretionary or self-managed actions
Poor adherence → has led to the creation of numerous individual-level health behavior theories designed to
understand why people do or do not adopt health-related behaviors
Focus of individual-level health behavior theories → cognitive variables:
Attitudes
Beliefs
Expectations
Individual-level health behavior theories → assume a rational-actor-model where individuals want to maximize
positive health outcomes through logical decision-making
Strengths of individual theories:
Serve as blueprints for developing and evaluating interventions.
Help identify key determinants of health behaviors to target and measure.
Aid in predicting future health actions.
Provide frameworks for understanding complex behavior patterns.
Challenges of individual theories:
Evidence for the usefulness of specific theories for particular behaviors or settings remains incomplete or
unclear.
There is significant overlap and redundancy among theories:
Many share similar constructs (e.g., “perceived control,” “self-efficacy,” “intention”) but use different
terminology.
This leads to an overwhelming theoretical landscape that can confuse researchers and practitioners.
6 major individual theories:
W1: Introduction to Health Promotion 2
, Social Cognitive Theory
Self-Regulation Model
Health Belief Model (HBM)
Theory of Planned Behavior (TPB)
Transtheoretical Model (TTM) (or stages of change)
Relapse Prevention model (RP)
1. Self Cognitive Theory
Bandura → self cognitive theory (SCT) = explains human behavior as the result of a reciprocal interaction
among:
Personal factors (beliefs, attitudes, cognition)
Behavior
Social and physical environment
SCT → reciprocal determinism = individuals both (1) influence and (2) are influenced by their environment and
behavior
SCT → key components:
Outcome expectations = beliefs about the consequences of performing a behavior
e.g., if I do X, Y will happen
Self-efficacy = beliefs about one’s ability to perform the behavior successfully
e.g., I am capable of doing X
Bandura considered self-efficacy as the most influential determinant of behavior
Behavior change depends on both believing a behavior will produce desirable results, and believing one is
capable of doing it
Self-efficacy affects:
Acquisition of new behaviors
Inhibition of undesired behaviors (discontinuation; e.g., quit smoking)
Disinhibition (e.g., resuming activity after illness)
Self-efficacy influences:
Choice of activities and settings
Effort and persistence
Emotional responses (e.g., anxiety/distress)
Cognitive patterns (e.g., rumination vs problem-solving)
Overall:
Low self-efficacy → focus on deficiencies and anxiety → poor performance
W1: Introduction to Health Promotion 3
, Self-efficacy expectations differ along:
Magnitude = perceived difficulty levels of tasks one feels capable of performing
Strength = confidence in one’s capability to perform the task
Generality = the extent to which confidence transfers across different situations
Example: cardiac patients may feel confident during supervised exercise (high SE) but not in unsupervised
exercise (low SE)
Sources of self-efficacy:
Performance accomplishments = mastery through direct experience is the most powerful source of SE
Success builds confidence, failure undermines it
Vicarious experience (modeling) = observing others successfully perform a task increases one’s own belief
in ability
Verbal persuasion = encouragement or motivational circumstances from others (e.g., health professionals)
can strengthen self-belief
Physiological state = bodily cues such as anxiety, fatigue, or pain influence perceived ability
High arousal or stress typically lowers self-efficacy
Modelling is especially successful if:
The model is similar in age, gender, or circumstance
The model’s success is portrayed as a result of effort, not ease
The behavior is rewarded
Health locus of control = belief about whether health outcomes are self- or externally controlled
Difference SE:
Locus of control is about believed control over outcomes
SE is about believed capability to perform behaviors leading to those outcomes
Bandura → believing one’s health is self-determined (locus of control) does not guarantee high self-efficacy if
one doubts their skills
Self-esteem = self-worth or self-respect
Difference SE:
Self esteem is about global evaluation of self-worth
SE is a domain-specific belief in capability
Bandura → one can have high efficacy without pride (e.g., brushing teeth) or low efficacy without low self-
worth (e.g., riding a unicycle)
However, people often build self-efficacy in areas that enhance self-esteem
SCT → key situational determinants:
Social norms (affect adolescent development)
Social support (influences health behavior)
Modeling (affects adolescent development)
W1: Introduction to Health Promotion 4
Literature
Huber, M., Knottnerus, J. A., Green, L., Van Der Horst, H., Jadad, A. R., Kromhout, D., & Smid, H (2011). How
should we define health?
WHO (1964) → health = a state of complete physical, mental and social well-being and not merely the absence of
disease of infirmity
At that time, this was revolutionary, broadening the idea of health beyond disease absence to include well-
being in multiple dimensions.
However, despite its influence, the definition has not been revised since 1948, even as global demographics
and disease patterns have evolved.
Increasing criticism suggests the definition is now outdated and counterproductive.
Limitations of the WHO definition:
Defining health as complete well-being is unrealistic and harmful
Changing disease patterns → when WHO issued the definition in 1948, acute diseases were dominant and
often fatal; today chronic diseases account for most morbidity and healthcare costs globally
The definition’s reliance on a “complete state” of health makes it impossible to operationalize or measure
effectively
Current health policy, research and clinical practice → rely on definitions that determine what is measured as
health gain
E.g., societal participation or coping capacity may be more relevant outcomes than full recovery for people
with chronic diseases
Ottawa Charter for Health Promotion (1986) = addressed social and personal resources and physical
capability
WHO never adopted this formally
Huber (2011) → health = the ability to adapt and to self-manage in the face of social, physical and emotional
challenges
Shifts health from a static state to a resilience-based process, integrating biological, psychological and social
adaption
Reflects dynamic understanding of health; emphasizing resilience, personal autonomy, and social
participation rather than unattainable perfection
Health can de defined across three domains:
Physical health = reflects an organism’s ability to respond, recover and maintain equilibrium under stress
Allostasis = the ability to preserve stability through change
Allostatic load = failure of allostasis; resulting in tissue damage and disease
Mental health = involved adapting coping and the maintenance of meaningful engagement with life
Sense of coherence = the mental capacity to find meaning, manageability, and comprehensibility in
stressful experiences
Social health = the ability to participate in society, fulfill roles, and maintain independence despite illness
W1: Introduction to Health Promotion 1
, Disability paradox = people can perceive high quality of life despite significant disability if they adapt
successfully
Stanford chronic disease self-management program → patient who learned self-management techniques
reported:
Improved self-rated health
Less fatigue and distress
Greater energy and social participation
Lower healthcare costs
Clark & Janevic (2014), Individual theories. The Handbook of Health Behavior Change
Individual adherence = whether people actually follow through on recommended behaviors such as taking
medications, keeping appointments, and making lifestyle changes
Non-adherence remains a major barrier to achieving positive health outcomes
Poor adherence is common whenever patients must take discretionary or self-managed actions
Poor adherence → has led to the creation of numerous individual-level health behavior theories designed to
understand why people do or do not adopt health-related behaviors
Focus of individual-level health behavior theories → cognitive variables:
Attitudes
Beliefs
Expectations
Individual-level health behavior theories → assume a rational-actor-model where individuals want to maximize
positive health outcomes through logical decision-making
Strengths of individual theories:
Serve as blueprints for developing and evaluating interventions.
Help identify key determinants of health behaviors to target and measure.
Aid in predicting future health actions.
Provide frameworks for understanding complex behavior patterns.
Challenges of individual theories:
Evidence for the usefulness of specific theories for particular behaviors or settings remains incomplete or
unclear.
There is significant overlap and redundancy among theories:
Many share similar constructs (e.g., “perceived control,” “self-efficacy,” “intention”) but use different
terminology.
This leads to an overwhelming theoretical landscape that can confuse researchers and practitioners.
6 major individual theories:
W1: Introduction to Health Promotion 2
, Social Cognitive Theory
Self-Regulation Model
Health Belief Model (HBM)
Theory of Planned Behavior (TPB)
Transtheoretical Model (TTM) (or stages of change)
Relapse Prevention model (RP)
1. Self Cognitive Theory
Bandura → self cognitive theory (SCT) = explains human behavior as the result of a reciprocal interaction
among:
Personal factors (beliefs, attitudes, cognition)
Behavior
Social and physical environment
SCT → reciprocal determinism = individuals both (1) influence and (2) are influenced by their environment and
behavior
SCT → key components:
Outcome expectations = beliefs about the consequences of performing a behavior
e.g., if I do X, Y will happen
Self-efficacy = beliefs about one’s ability to perform the behavior successfully
e.g., I am capable of doing X
Bandura considered self-efficacy as the most influential determinant of behavior
Behavior change depends on both believing a behavior will produce desirable results, and believing one is
capable of doing it
Self-efficacy affects:
Acquisition of new behaviors
Inhibition of undesired behaviors (discontinuation; e.g., quit smoking)
Disinhibition (e.g., resuming activity after illness)
Self-efficacy influences:
Choice of activities and settings
Effort and persistence
Emotional responses (e.g., anxiety/distress)
Cognitive patterns (e.g., rumination vs problem-solving)
Overall:
Low self-efficacy → focus on deficiencies and anxiety → poor performance
W1: Introduction to Health Promotion 3
, Self-efficacy expectations differ along:
Magnitude = perceived difficulty levels of tasks one feels capable of performing
Strength = confidence in one’s capability to perform the task
Generality = the extent to which confidence transfers across different situations
Example: cardiac patients may feel confident during supervised exercise (high SE) but not in unsupervised
exercise (low SE)
Sources of self-efficacy:
Performance accomplishments = mastery through direct experience is the most powerful source of SE
Success builds confidence, failure undermines it
Vicarious experience (modeling) = observing others successfully perform a task increases one’s own belief
in ability
Verbal persuasion = encouragement or motivational circumstances from others (e.g., health professionals)
can strengthen self-belief
Physiological state = bodily cues such as anxiety, fatigue, or pain influence perceived ability
High arousal or stress typically lowers self-efficacy
Modelling is especially successful if:
The model is similar in age, gender, or circumstance
The model’s success is portrayed as a result of effort, not ease
The behavior is rewarded
Health locus of control = belief about whether health outcomes are self- or externally controlled
Difference SE:
Locus of control is about believed control over outcomes
SE is about believed capability to perform behaviors leading to those outcomes
Bandura → believing one’s health is self-determined (locus of control) does not guarantee high self-efficacy if
one doubts their skills
Self-esteem = self-worth or self-respect
Difference SE:
Self esteem is about global evaluation of self-worth
SE is a domain-specific belief in capability
Bandura → one can have high efficacy without pride (e.g., brushing teeth) or low efficacy without low self-
worth (e.g., riding a unicycle)
However, people often build self-efficacy in areas that enhance self-esteem
SCT → key situational determinants:
Social norms (affect adolescent development)
Social support (influences health behavior)
Modeling (affects adolescent development)
W1: Introduction to Health Promotion 4
