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Much of the credit for today's public promotion model belongs to Keith Tone, a public health practitioner, who is best known for his health education, empowerment and health promotion model. In this model, Tone and Tilford (2001) identified educational, preventative empowerment and radical approaches to promoting public health and acknowledge that each has its merits (in Earl and Wills, 2007 Ch 5, p152). The model tries to address social and environmental inequalities, which influence individuals and communities. "Health education is seen as a driving force empowering lay and professional people by raising their consciousness of health issues, policies and choices" (Earl et al 2007). For example, (k311, DVD, Video 1.2.2) At the Sure Start Centre, there is a diverse of resources, not just for the mother and babies but involving the fathers thereby empowering them with health promoting issues i.e. raising awareness of available resources to them . These views are complemented by Earl and Wills (2007) who also argue that communities and health professional bodies can prepare themselves for change and begin to effect the transformation of public policy. Despite his wealth of experience and their obvious enthusiasm for providing health education, Tone identified lack of clarity around the specific problem of health promoting behaviours in that they are often less pleasant than the alternatives on offer at the time which makes outcomes biased at any given time. On the other hand Tone maintains that the most reliable evidence which came from normative and analytical models of health promotion encourage the collection interpretation of valid, important and applicable research derived evidence. Ewels and Simmnett (2003), argued that there is no right approach to promoting health and that individuals need to work out for themselves how best they can go about promoting health by drawing their own values and own professional conduct. The spheres in the model overlap each other, Earl and Wills (2007 p. 154). Against the background of tightening financial constraints, risk reduction and professionals trying to maintain status in the face of increased health education, the promotion of this view evidence has been powerful. For instance, (Design for life , Oxfam article) " Oxfam has run businesses and marketing courses, and provided funds for packaging, a community magazine, a website, and a brochure. Despite widespread use of the term, conceptual ambiguity undermines efforts to put health empowerment as the nucleus of public promotion. The National Health Service (NHS Plan, 2000) was launched to a prevent inadequacies in the public health polices. As would be expected, public health today is affected by both new and old diseases (Donaldson, 2000). The NHS is tirelessly aiming to reach all individuals encouraging them to lead healthier lives, while respecting their autonomy. Arguably any debate of self empowerment is superficial without health education. As a consequence, there has been a concentration across all levels of health care delivery on the importance of making a health promotion public policy produced, synthesized, disseminated and used in practice. Health protection deals with regulations and policies such as implementation of work place smoking policy in the interest of providing clean air or commitment of public funds of accessible leisure services (Earl et al p 153). The World Health Organisation (WHO) has devised numerous policies and interventions that have a positive influence on the health of the general population. These policies try to address health inequalities through for example, combating poverty, social inclusion, and sustainable development across governments. By making explicit the links between core values' and principles and different kinds of practice, a greater understanding of the philosophy and priorities of promoting public health may be derived Naidoo and Wills (2000). According to Tone and Tilford (1994), Health promotion is a process that is primarily concerned with assessing health related activity against values and goals in such a way that the results contribute to future decision making. For instance, information giving, regardless of whether professionals consider the information to be in the service user's best interests, thereby providing informed choice. More specifically health promotion is mediated through publicising and supporting health promotion campaigns Earl and Wills (2007 p.154). The centrality of this relation focuses on positive action 'what has been achieved' and knowledge-building. However, Tone (2000) suggests that the limitation of outcome evaluation is that it provides no insights into what actually occurred during the programme, but only the end product. This model examines the development of health research literature which focuses on education. Failure of evaluation and research leads to ineffective and unsuccessful health promotion which will remain limited in scope and nature. When process and outcome evaluation are combined, the evaluation focuses on monitoring the process of change that occurs as the result of a health intervention as well as the factors that facilitate or prevent desired changes (Health Education Board for Scotland 1999).
The prime focus of theories is to explore the determinants of health behaviour in health and social care which put behavioural change at their core. According to National Institute for Health and Clinical Excellence (NICE, 2007 p 10) human behaviour is "the product of individual or collective human actions, seen within and influenced by their structural, social and economic context". There are many current initiatives which are attempting to dovetail behavioural approaches to all issues of health promotion which includes the commonly used Health Belief Model HBM, The Transtheoretical Model TTM and the Health Action Model HAM. Briefly, the paper will outline and explore each of the above models and will draw more emphasis on the TTM. The Health Belief Model (Becker 1974) focuses on the public perceptions of why individuals would participate or not in research. It also made up of four components: perceived susceptibility, perceived severity, perceived benefits and perceived barriers. In attempting to establish critical thoughts regarding the HBM health promotion it is first necessary to establish a shared understanding of the process of behavioural change. Each of the perceptions can be used individually to explain the behavioural processes. The "HBM suggests that behaviour change is a result of a process in which information is carefully scrutinised and weighed up before a decision is reach and that individual behaviour will be guided by 'rationality' of protecting one's health"(Earl et al 2007, p133). On the contrary this could be misleading as an individual may not be clear about different aspects of interpretation in relation to determinants of health actions, and this also encourages unreflective eclecticism. It has also been noted that the HBM is not diverse as it is 'individual based' which does not acknowledge community action approach. No man is an island. The Health Action Model (Tones, 1988) tries to take account of strong motivating forces - such as hunger, pain, pleasure and sex - in order to understand why people act in seemingly irrational ways (Earl et al 2007, p 137). HAM theory provides a framework for relating beliefs to other motivating factors are considered as predisposing, individual skills and environment are considered as enabling, the normative pressures is considered as reinforcing each of which can influence the intention to action. However personal choice also plays an important role. "People are rational, aware self creating agents of their own healthâ€¦.influenced by consciously chosen goals (British Medical Journal Vol. 329, p 1400). For instance, it is expected for people to have good hand hygiene, despite the intent, if there is lack of facilities this is unlikely to happen. In the present climate, health care practitioners may not take account of the social inequalities in educational provisions or assess due to language barriers and different cultures in the health and social care.
The Transtheoretical model TTM is attributed to Prochaska and DiClemente, 1984. This theory evolves on the on going process of change and assumptions of behaviour changes as outlined by (Earl et al 2007 p135). The TTM provides a useful way of tailoring interventions at which people are in the change process (Earl et al 2007, p 135). In the author's line of work as a mental health practitioner, this model is commonly used, with services users who have addictive habits such as alcoholism, drug misuse. Beattie (1984) suggested that health promotion can be developed to highlight the assumptions and frameworks underpinning different ways of engaging in practice.
The two psychologists identified five levels of motivation which are pre-contemplation, contemplation, preparation, action and maintenance. Precontemplation is identified as ignorance of a problem and lack of motivation to change. For instance, at times dealing with a service user with drug problems might mean that they not have educational provisions and insight. Contemplation brings some self awareness but not intending to change the habit/way of life (Prochaska & DiClemente, 1994). For example, a service user with alcohol problems might have knowledge and insight and therefore, readily willing to get help and change whilst in hospital. Preparation is marked by small cognitive and behavioural changes (Prochaska & DiClemente, 1994). For instance, a service user who has identified their erroneousness of drug misuse might gladly embrace a new lifestyle of healthier living. Action involves further cognitive and behavioural changes. Service users in this category will readily embrace all the stages above and mostly are allocated support in the community after discharge to keep them afloat. Finally, maintenance involves active preservation of changes made at previous stages to avoid relapse (Prochaska & DiClemente, 1994). This stage is when services users are given techniques and resources to utilize after discharge in order to avoid a vicious cycle.
Given the relative TTM model, there is a strong argument for its structural stages of change. Many theorists have argued that it lacks scientific evidence. West (2005) outlined that the (TTM), gives false outcomes instead of providing evidence - based outcomes because they are based upon scientific models, in reality, the appeal of TTM for this purpose appears intuitive.