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  • Published: 01 December 2023

Health promotion, the social determinants of health, and urban health: what does a critical discourse analysis of World Health Organization texts reveal about health equity?

  • Michelle Amri 1 , 2 , 3 ,
  • Theresa Enright 4 ,
  • Patricia O’Campo 5 , 6 ,
  • Erica Di Ruggiero 3 ,
  • Arjumand Siddiqi 5 , 7 , 8 &
  • Jesse Boardman Bump 2 , 9  

BMC Global and Public Health volume  1 , Article number:  25 ( 2023 ) Cite this article

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The World Health Organization (WHO) has focused on health equity as part of its mandate and broader agenda—consider for example, the “health for all” slogan. However, a recent scoping review determined that there are no studies that investigate the WHO’s approach to health equity. Therefore, this study is the first such empirical analysis examining discourses of health equity in WHO texts concerning health promotion, the social determinants of health, and urban health.

We undertook a critical discourse analysis of select texts that concern health promotion, the social determinants of health, and urban health.

The findings of this study suggest that (i) underpinning values are consistent in WHO texts’ approach to health equity; (ii) WHO texts reiterate that health inequities are socially constructed and mitigatable but leave the ‘causes of causes’ vague; (iii) despite distinguishing between health “inequities” and “inequalities,” there are several instances where these terms are used interchangeably across texts; (iv) WHO texts approach health equity broadly (covering a variety of areas); (v) health equity may be viewed as applicable either throughout the life-course or intergenerationally, which depends on the specific WHO text at hand; and (vi) WHO texts at times use vague or unclear language around how to improve health equity.

Conclusions

This study does not present one definition of health equity and action to be taken. Instead, this study uncovers discourses embedded in WHO texts to spur discussion and deliberate decision-making. This work can also pave the way for further inquiry on other complex key terms or those with embedded values.

Peer Review reports

The World Health Organization (WHO) has long emphasized health equity as a central tenet of its work. In the Declaration of Alma-Ata in 1978 [ 1 ], for example, the WHO explicitly underscores its goal of “promot[ing] the health of all the people of the world.” More recently, this focus on health equity has been emphasized in the work of the WHO’s Commission on the Social Determinants of Health (CSDH; [ 2 ]). However, what health inequity has meant in practice is not entirely clear. In response, the WHO commissioned Margaret Whitehead to define inequity in health in 1990. According to Whitehead, inequity in health equated to “differences which are unnecessary and avoidable … [and] considered unfair and unjust ” [ 3 ]; a definition that has been praised as accessible, concise, intuitive, and easily communicated [ 4 ]. Although this definition has been widely accepted and used internationally, scholars have noted there is ambiguity respecting the distinctions between health inequity, health inequalities, and health disparities [ 4 , 5 ]. This ambiguity is apparent both in the definition of health inequity and its operationalization, a dilemma that is not specific to the WHO. Although health inequity entails a normative assumption that inequities are unfair, health inequality is a measured difference [ 6 ]: that is, a descriptive definition that does not entail being unfair. However, it is immensely difficult to determine what is in fact a health inequity as opposed to an inequality. Characterizations of health inequity (e.g., unnecessary, unfair) are open to varying interpretations which can be problematic [ 4 , 7 ]. To illustrate, differences can arise if one policymaker understands unfair to mean with respect to counterparts in a similar socioeconomic position (SEP) or socioeconomic status (SES) [ 8 , 9 ] in the same city, whereas another may interpret unfair to mean with respect to the population-at-large; or if one policymaker understands avoidable as meaning a health inequity can be remedied through the healthcare system, whereas another understands this to mean a change in policies affecting the social determinants of health, and yet another through changing the political climate itself. In the context of health, then, the definition of equity has consequences for its operationalization [ 10 ], as these differing understandings result in different approaches to policy and practice. This is problematic for both how health equity is understood and for the execution of subsequent action (e.g., implications for measurement and accountability [ 5 ]).

In response to identified ambiguities, a recent scoping review of the WHO’s approach to equity [ 11 ] was undertaken to systematically search the peer-reviewed literature to understand how equity has been referred to and its conceptual underpinning [ 12 ]. This review determined that the WHO has held—and continues to hold—ambiguous, inadequate, and contradictory views of equity [ 12 ]. For example, some scholars felt that the WHO approaches health equity through largely focusing on SES, whereas other times the WHO focuses on various facets of inequity. It is noteworthy that this scoping review found no empirical articles, of either a quantitative or qualitative nature, assessing the WHO’s interpretations and approaches to equity, despite not restricting the search. Given these ambiguities, our study seeks to fill this gap in the research and empirically examine how the WHO conceptualizes health equity by conducting a critical discourse analysis (CDA) of select texts concerning health promotion, the social determinants of health (SDH), and urban health. CDA, a method and methodology used in the social sciences, is employed because it can help tease out how health equity is used in WHO texts by assessing what language is used, how it is used, and what is not being stated. Through this empirical analysis, we aim not only to arrive at a more nuanced understanding of health equity, but also to unveil understandings of implicit normative positions that are reflective of the WHO’s work. And not only the WHO’s work, but other global health work, given the overarching power the WHO possesses and its role to act as the “directing and co-ordinating authority on international health work”, as outlined in its constitution [ 13 ].

  • Critical discourse analysis

CDA is a method and methodology that investigates how phenomena are discussed. Given that values are inherent in the WHO’s approach to health equity, CDA is one method that rejects value-free science [ 14 ]. CDA allows for building on multiple understandings and interpretations of health equity by centering inquiry around discourses, which can be defined broadly as “anything beyond the sentence, language use, and a broader range of social practice that includes non-linguistic and non-specific instances of language” [ 15 ]. The WHO’s discourses are worthy of study given that the WHO is regarded as the authoritative voice on global health, and how it writes and talks about phenomena has a significant impact on individual attitudes and behaviors as well as public policies.

Because CDA can allow for the understanding of discourses [ 14 ], uncovering underlying narratives of ideologies and claims, and the identification of contradictions, gaps, and unrealized possibilities for change [ 16 ], it affords a well-suited method and methodology for this study. The WHO, as an organization, is made up of multiple intersecting parts and processes—and these dynamics ultimately shape how the WHO can and does speak about phenomena. Additionally, CDA was selected for this study because it affords a critical perspective that ultimately seeks to combat inequity [ 14 ]. Overall, this study employs a non-prescriptive methodology to read texts closely to uncover discourses and present insights about health equity that other methods do not afford [ 17 ].

Approach to analysis

CDA neither has a unitary theoretical framework nor denotes a specific approach to conducting research [ 14 ] or a specific sampling procedure [ 18 ]. With this approach of assessing language use in texts, the texts themselves constitute data in the analysis (Table  1 ). Each datum was analyzed by MA using both a priori, or deductive, and inductive codes. A priori codes—“equity or inequity” and “equality or inequality”—facilitated the analysis of how these terms are used. In addition, applying the question “equality of what?”, famously posed by Sen [ 19 ], or a variation of “health inequities in what?” allowed for further insights when investigating the a priori codes. Inductive codes—such as “intergenerational,” “what is inequity?”, and “indirect or unclear”—emerged from careful reading of texts to observe aspects not covered by the a priori codes, which allowed for enhanced consideration of discourses. Both a priori and inductive codes facilitated the categorizing of language and the reassessment of these categories through additional data when new discourses presented—in line with CDA [ 18 ]. Analysis was conducted across texts and not as a distinct list per datum, which guided analysis and the construction of the findings section. This exploratory discursive analysis was not conducted with the intention of weighing or ranking texts and their relationship to these discourses, or to uncover findings along set themes in a framework. Instead, the goal was to analyze discourses. “Positionality”, drawn from critical social science research, implies that one’s position may influence various aspects of the research, such as in collecting or interpreting data [ 20 ]. Thus, the primary coder (MA) and her positionality is understood to influence analysis. She is a social science researcher in global and public health with experience consulting for the WHO. She led the scoping review focused on the WHO’s approach to equity [ 11 ], and thus, her experience has informed this CDA. The positionality of all authors whose works align with the critical tradition as opposed being squarely situated in biomedical science also influence this study. As MA presented emergent discourses with illustrative quotes from the texts analyzed, the entire authorship team reviewed the coded text and corresponding findings and discussed discrepancies to reach consensus. NVivo 12 software was used to code the texts.

Data sources

The data sources, listed in Table  1 , concern health promotion, the SDH, and urban health. These three domains were selected because they are cross-disciplinary, focus on upstream solutions, and provide different perspectives on health equity. These three areas are relatively easy to compare because they are all related. Health promotion attempts to address broad determinants of health inequity. The SDH reflect an upstream perspective. And urban health was selected because cities are where inequities are greatest. Within these domains, we used a multi-step process to select texts. We began with search results from a scoping review on the WHO’s concept of equity in health that yielded 2558 hits [ 12 ]. We reviewed these results keeping a list of WHO texts that were cited, discussed, or mentioned. In tracking these results, we focused our attention on texts appearing multiple times and focused on health equity, an approach which allowed us to narrow our analysis. We applied several criteria for our assessment. We included texts published from 2008 until 2021, when the CDA was conducted. Given the influence of the CSDH’s work, particularly in terms of shifting understanding around the SDH [ 29 ], the CSDH’s final report was the first text included in this study, with all the preceding reports being excluded. Texts from CSDH Knowledge Networks, such as the Early Child Development or Employment Conditions Knowledge Networks, were excluded because their direct focus is outside of the three outlined domains. The only exceptions were the texts from the Knowledge Network on Urban Settings, which focused on urban health, and the Priority Public Health Conditions Knowledge Network, which focused on equity and the SDH explicitly in the title of the included text. We assessed the influence of WHO texts based on the number of times texts were mentioned in the search results. For example, the Rio Political Declaration on Social Determinants of Health [ 26 ] was mentioned in nine hits [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ]. We also recognized that quantitative measures for assessing influence are limited given that texts may be prominent but not explicitly mentioned. To balance this challenge, we applied our knowledge of the field to better identify prominent and influential texts in these domains (e.g., major global report, political declaration). We elected to focus in at the institutional level, so we included different types of texts because WHO discourses are shared through different channels. Similarly, we did not restrict our selection by geographical region (e.g., regional- or country-levels). We also sought texts that explicitly cite and/or mention each other to uncover discourses across texts. This decision also aligns with CDA methodologically to assess interrelated systems of knowledge (please see Fig.  1 and discussed further below). Applying these criteria, we identified nine texts, and the final list of texts to be analyzed was discussed by the authorship team prior to analysis commencing.

figure 1

Depiction of interrelations: cross-referencing between selected texts

These nine texts included in the CDA listed in Table  1 , begin from the CSDH’s final report, Closing the gap in a generation , and include reports providing an overview on issues, a conference, a tool, and a user manual, and includes a political declaration. The selected texts are interrelated, which is most noticeable when assessing cross-references, as shown in Fig.  1 . A linkage between texts that reference each other is depicted by a thick, solid line and instances in which a text is mentioned but not explicitly referenced are depicted by a dashed line. An example of this latter relationship is in Our cities, our health, our future (text 2 in Fig.  1 ), which does not cite the CSDH’s final report (text 1), but expresses that the CSDH’s framework guided the Knowledge Network on Urban Settings’ (KNUS) work [ 21 ]—this could be because the CSDH’s final report had not yet been published when the report was prepared. As another example, Equity, social determinants and public health programmes (text 3) cited the CSDH’s website, mentioned it in the forward, and had a full page dedicated to the CSDH’s report ([ 22 ] p. 292), but it did not explicitly cite the CSDH’s final report (text 1). Also, although the Urban HEART User Manual (text 5) did not explicitly cite the Urban HEART: Urban Health Equity Assessment and Response Tool key report (text 4), it is evidently based on this work. On the other hand, although Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings (text 6) discusses Urban HEART and cites the Urban HEART report (text 4), it does not cite the user manual (text 5), resulting in no relationship in Fig.  1 . Notably, neither the Rio Political Declaration on Social Determinants of Health (text 7) nor Promoting health in the SDGs, Report on the 9th Global Conference for Health Promotion: All for health, health for all (text 9) cited any sources, which results in no solid line relationships in Fig.  1 . Overall, many of the texts mention each other, demonstrating interrelated systems of knowledge, which aligns with CDA methodology.

Selected texts are written by various authors, including the influential CSDH, and associated KNUS and Priority Public Health Conditions Knowledge Network (PPHCKN); the WHO Centre for Health Development (Kobe Centre), and in two instances co-authored with the United Nations Human Settlements Programme (UN-Habitat); and WHO more broadly. These texts describe health situations, but also include the Urban HEART User Manual and the Rio Political Declaration on Social Determinants of Health . Additional information on texts’ author(s) and select authorship acknowledgements is chronicled in Additional file  1 .

The proceeding results demonstrate that (i) underpinning values are consistent in WHO texts’ approach to health equity, which aligns with the findings from Amri et al. on how scholars perceive the WHO’s approach to equity [ 11 ]; (ii) WHO texts reiterate that health inequities are socially constructed and mitigatable but leave the “causes of causes” vague, such as colonization, which may make policy efforts unfruitful without fully understanding what these are; (iii) despite expressing a distinction between health “inequities” and “inequalities,” there are several instances where WHO texts use “inequity” and “inequality” interchangeably across texts; (iv) WHO texts approach health equity broadly (e.g., including resources for health; determinants; outcomes or disparities in health and healthcare; consequences of specific diseases, conditions, or environments; allocation and utilization of resources; access to care or quality curative services; health opportunities and outcomes; and the organization of society); (v) depending on the specific WHO text at hand, health equity may be viewed as applicable throughout the life-course or intergenerationally, each of which has implications for policies and programs put forward; and (vi) WHO texts at times use vague or unclear language around how to tackle health inequities. These results are outlined in Table  2 and discussed in detail below.

Consistent underpinning values

The texts analyzed demonstrated alignment with Whitehead’s definition of health inequity [ 3 ], which was commissioned by the WHO. As stated above, Whitehead defines inequity in health as “differences which are unnecessary and avoidable … [and] considered unfair and unjust ” [ 3 ]. For examples of excerpts that align with Whitehead’s language, please see Table  3 . As a set, these links demonstrate the pervasive and ingrained nature of Whitehead’s definition and consistent underpinning values.

In Equity, social determinants and public health programmes , it is noted that “health equity is a moral position as well as a logically-derived principle” and that “there are both political proponents and opponents of its underlying values” [ 22 ], reiterating this understanding of the values inherent in health equity. What comes across consistently is the notion that “health equity is social justice in health” [ 27 ] and that action on health inequities is rooted in the “principles of justice, participation, and intersectoral collaboration” [ 2 ]. In fact, in Urban HEART: Urban Health Equity Assessment and Response Tool , it was stated that “we know how to reduce inequities with known interventions and to not take action is unjust” [ 23 ]. Therefore, to advance and take action, actors must first ensure they have shared values, as some scholars believe shared values are required for political decision-making [ 39 ].

However, occasionally this overt social justice approach to health inequity does not come through in the texts. For instance, “an example of an inequitable abortion policy would be allowing individual medical practitioners to apply their own values to decisions about whether women should have access to safe abortion or making safe abortion services accessible to rich women but not poor women” [ 22 ]. Although the latter example around making abortion services only accessible to rich women aligns with Whitehead’s definition of health inequity, the former example around allowing individual medical practitioners to apply their own values to decisions does not necessarily constitute a systematic difference that is unjust or unfair, without additional contextual factors at play (e.g., if this is the only medical practitioner in the area). Or as another example of the social justice approach to health inequity being less clear is in a reference to the WHO’s Framework Convention on Tobacco Control (FCTC) as an “equity lever” for “conferring power on the many developing countries that otherwise would not be able to stand up to the tobacco industry” [ 22 ]. Though one could argue that although the FCTC is of assistance, it does not necessarily mitigate unjust and unfair systematic differences in health.

Socially constructed and mitigatable

All assessed texts shared an understanding that health inequity is not a “condition of nature” or “randomly assigned”, whether explicit or implicit. Instead, health is “shaped by deeper social structures and processes … produced by policies that tolerate or actually enforce unfair distribution of and access to power, wealth, and other necessary social resources” (emphasis added; [ 2 ]), and similarly, “how health is distributed within a population is foremost a matter of fairness in economic and social development policy ” (emphasis added; [ 22 ]). In addition to noting that health inequities result from policy , there is mention of the need for “broad and integrated interventions that address the underlying causes of inequity that result in poorer health and worse health outcomes” (emphasis added; [ 21 ]) or “focus[ing] on the ‘causes of the causes’” [ 2 ]. However, what constitutes these “underlying causes of inequity” is largely left vague; for example, “health inequities result from unequal distribution of power, prestige and resources among groups in society” [ 22 ], “the underlying causes of the causes of inequities are often associated with social status, discrimination or exclusion” [ 21 ], and “health inequities are the result of the circumstances in which people grow, live, work and age, and the health systems they can access, which in turn are shaped by broader political, social and economic forces” [ 25 ]. Although mitigating health inequities through policy is needed, this focus will not necessarily address the underlying causes of health inequities if the WHO is unsure of what they are or is unwilling to name and target them. Understandably, naming these causes can be complex, and the causes of health inequities can be wide-ranging; however, by not formally recognizing these causes, there is no subsequent impetus to address them. In other words, if causes are named, organizations and individuals should then act and disrupt the status quo, which, at present, benefits them. As such, there is little incentive for those in positions of power or privilege, such as the WHO, to name and target causes of causes, which may be a result of relying on influencers who preclude the naming of causes of causes. This lack of naming the causes of causes exists despite expressing that improving health “ depends on understanding the causes of these inequities and addressing them” [ 22 ]. Similarly, what constitutes good policy [ 22 ], although well-intentioned, may be subjective (e.g., does it entail policy that is evidence-informed, addresses the SDH, promotes universal access to resources that may improve health, or does it entail something else altogether?).

But with so much attention paid to policy, arguably, sufficient attention should also be allocated to other areas, such as governance. Is it that adopting better governance is difficult to achieve or not well-defined? Is it that improvements in health indicators but not health equity are prioritized in WHO texts? Or are there other reasons?

Questions emerge as we assess the language employed when defining health in/equities. For example, when distinguishing between health inequities that are “systematic differences in health [that when] judged to be avoidable by reasonable action they are, quite simply, unfair” [ 2 ], the inclusion of “avoidable by reasonable action” draws debates around what constitutes both “avoidable” and “reasonable,” with the former discussed by Bambas and Casas [ 40 ]. And in terms of the latter, the CSDH identifies various actions across different levels, including community mobilization, multisectoral action, and progressive taxation, but whether these actions are reasonable is likely dependent on individual discretion and their context (e.g., multisectoral action may be deemed “reasonable” in one’s jurisdiction if there is political will and established systems for liaising that enable multisectoral action [ 41 ], as opposed to more innovative multisectoral approaches not previously undertaken [ 42 ]).

Similar questions emerge from statements such as “most individuals and societies, irrespective of their philosophical and ideological stance, have limits as to how much unfairness is acceptable” and “[health inequities] are avoidable, in that there are plausible interventions” [ 22 ]. The use of “unfair” is addressed in Urban HEART Urban Health Equity Assessment and Response Tool , which indicates that “although ideas about what is unfair may differ to a certain degree from place to place, there is much common ground. For example, it would be widely considered unfair if the chance of survival was much poorer for the children of some socioeconomic groups, compared with that of others” [ 23 ]. But given the global scope of the WHO’s work, there remains potential for different cultural and political understandings around what constitutes fairness.

Differentiating health inequity from inequality

As established above, health inequities are thought to be unnecessary, avoidable, unfair, and unjust. These conditions help differentiate health inequities from health inequalities in the texts analyzed, which are thought to be measured differences that are not unfair and unjust [ 6 ]. Consider the following statement from Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings : “some health inequalities are not health inequities. For example, death rates among people in their eighties are higher than those among people in their twenties, but this is not a socially produced, unfair health inequity. Rather, it is the result of the natural biological process of ageing” [ 25 ].

This distinction between health inequities and health inequalities is also expressed in Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings [ 25 ], in which health inequalities are defined as “simply differences in health between groups of people. These differences might be due to non-modifiable factors such as age or sex, or modifiable factors such as socioeconomic status.” Similarly, health inequities are defined as being “systematic, socially produced (and therefore modifiable) and unfair” [ 25 ]. In large part, this differentiation did align with the use of these terms in the texts analyzed. For example, in discussing the equity gauge approach, the CSDH [ 2 ] discusses the gauge as an approach to address “unfair disparities in health and health care.”

Given the emphasis placed on health inequities being unjust and unfair, there are instances where “inequalities” is used where the more appropriate term would be “inequities.” Instances of the occasional interchanged use of these terms include indicating: that “health inequalities in urban areas need to be addressed in countries at all income levels” [ 21 ], that “promotion of exclusive breastfeeding can still contribute to reducing mortality inequalities, because fewer than half of the poorest children in low- and middle-income countries are exclusively breastfed” [ 21 ], that “relying on city averages, rather than examining differences between neighbourhoods and urban subgroups, has further obscured inequalities within cities” [ 25 ], that “large inequalities have emerged between city dwellers, and urban slums have become a feature of many cities” [ 25 ], and that “a common theme across all global initiatives on health in cities has been the need to tackle inequalities in health” [ 27 ]. Given these outlined examples, by writing “inequalities” instead of “inequities,” the focus is then on the measured difference rather than their unjust and unfair nature and, thus, addressing these health inequities. Although the selection of “inequalities” in place of “inequities” could be based on geographic differences in terminology use or editorial changes, this does not align with what is presented in each of the texts analyzed (see Table  3 ).

WHO texts have also used these terms interchangeably when applied to outcomes, which is illustrated by contrasting statements by Blas et al. [ 22 ]: “in the United Kingdom, alcoholic cirrhosis used to be a rich man’s disease [ 43 ], but there was a shift (in England and Wales) in the relative index of inequality in male liver cirrhosis mortality by social class from 0.88 in 1961 to 1.4 in 1981 (i.e., from lower to higher mortality in lower socioeconomic categories),” with an example provided to explain health inequities “[i]n Glasgow, Scotland, male life expectancy varies from 54 to 82 years, depending on the part of the city in which the person lives” [ 25 ]. Additional sample excerpts are noted in Table  4 . Although these statements are not inaccurate, they do not align with WHO texts’ expressed position that these health inequalities are unjust and unfair and thus, health inequities.

Interestingly, there is a footnote mention of the use of “inequities” over “inequalities” in health in the violence and unintentional injury chapter in Equity, social determinants and public health programmes [ 22 ]. After indicating that “injuries are a major contributor to inequities 2 in health,” the footnote clarifies that “there are different views on the use of language. The authors of this chapter had originally inclined to the use of ‘inequalities’ in health, but, in the interests of consistency, have adopted the terms used elsewhere in this volume” [ 22 ].

Although the examples of interchanged use noted above and in Table  4 may be due to a lack of globally accepted differentiation [ 44 ] or various authors working on texts who may use the terms in different ways, a lack of understanding of the difference between these two terms or need to distinguish them, little attention paid to nuance by report writers, among many other potential reasons, it appears there is an intentional switching of terms at times. For example, despite the Global report on urban health: equitable, healthier cities for sustainable development indicating that data across 102 countries was analyzed to determine “health and health inequities,” one objective of this analysis of 102 countries was to “identify patterns, magnitudes and trends of health inequalities in urban settings at the national level on key health and social determinants of health indicators,” whereas another objective was to “identify health inequities in selected cities where sample sizes were sufficiently large and data were reliable” (emphases added; [ 27 ]). Similarly, the “widespread use of socioeconomic stratification variables, in particular asset quintiles, allows monitoring inequities in coverage and impact indicators on a regular basis. Most surveys are representative for subnational areas, thus also allowing the study of regional inequalities ” (emphasis added; [ 22 ]). Further, “addressing food safety inequities involves evaluating the effectiveness of interventions in reducing inequalities in food safety” (emphasis added; [ 22 ]). The rationale for this usage of the two terms is unclear. We can speculate that in these instances “inequalities” is specifically referring to the measured difference that is unjust and unfair; however, this is not always in alignment with how the terms are used.

Additionally—although different from interchanging terminology—the use of adjectives when referring to health inequities can muddy waters. Consider the following sentence: “when such differences, or inequalities, are not random but are systematic, and not due to biologically determined factors but due to modifiable social factors, they are unjust inequities” [ 27 ]. This use of “unjust” prior to “inequities” raises questions about whether just inequities exist. Similarly, the use of “unacceptable” in “unacceptable health inequities require political action across many different sectors and regions” [ 28 ] raises questions around what constitutes an acceptable health inequity. And lastly, the inclusion of “socially determined” prior to “health inequalities” in “the attention to socially determined health inequalities is a common feature of the observatories, which necessitates an intersectoral and community inclusive approach in both generating and applying the data” [ 27 ] raises questions on how “socially determined health inequalities” differ from health inequities. Evidently, this language could be more precise, for example, by using “politically determined” as opposed to “socially determined.”

Health inequities in what?

Drawing on the question of “health inequities in what?”—adapted from the question posted by Sen: “equality of what?” [ 19 ]—may lead to better understanding what discussions of health equity can center around and ultimately, potentially allow for more deliberate action [ 45 ]. Blas et al. [ 22 ] indicate that “three principal measures are commonly used to describe health inequities,” which are health disadvantages, health gaps, and health gradients. However, health equity is presented in the analyzed texts in terms of the unequal distribution of various “things,” including resources for health; determinants; outcomes or disparities in health and healthcare; consequences of specific diseases, conditions, or environments; allocation and utilization of resources; access to care or quality curative services; health opportunities and outcomes; and the organization of society. Select excerpts are presented in Table  5 to illustrate these various aspects. Carefully specifying and considering the question “health inequities in what?” is crucial because it can entail differing philosophical perspectives. Rawlsian theory would seek to distribute resources based on individual need, whereas Sen’s theory recognizes that the provision of goods will not result in the same outcome for individuals, and thus focuses on maximizing individual capabilities to function or equalizing capabilities among individuals [ 43 , 46 ]. Each of these theories provide different interpretations for how to strive for health equity, which must be taken into consideration. Ultimately, this demonstrates the need to clarify what discussions of health equity may be referring to more precisely.

Health equity as applicable throughout the life-course or intergenerational?

Select texts used language around the intergenerational aspect of health inequity, whether stated directly (e.g., “this reinforces the inequities in the distribution of other health conditions and can carry important intergenerational consequences” ([ 22 ], p. 121)) or indirectly (e.g., “inaction has detrimental effects that can last more than a lifetime” ([ 2 ], p. 59) and “this affects children as well, as whole families are bonded under the kamaiya system” ([ 2 ], p. 77)). However, this intergenerational way of thinking about health equity does not align with select expressions of public health action, in particular, targeting health through the life-course , which has been encouraged in WHO texts (e.g., “at the heart of it all is the challenge of health equity–ensuring that all people have the opportunity to achieve good health and affordable access to the health care they need throughout the life-course” ([ 27 ], p. 30)). These differing discourses are notable, as the policy and program actions that WHO texts are presenting as potential solutions do not explicitly discuss intergenerational aspects. By considering health equity as intergenerational, actions need to align with this discourse, including efforts that target sustained benefits over generations and associated long-term evaluations of efforts.

Vague or unclear approaches to improving health equity

Despite the texts’ focus on health equity and their aim to bring about change, much is frequently left unstated about how to proceed. This is best illustrated through commonplace language around the need for an “equity lens,” which was simply stated and without further explanation. One example that drew on the language of “equity lens” that did in fact provide specificity was indicating the need to

build capacity in applying the equity lens to the monitoring instruments and methodologies themselves. For example, population sampling frames are often based on physical address area codes, excluding the many vulnerable, informal settlers who do not have an official physical address. The public health community needs to be highly critical of its monitoring and surveillance tools and methodologies, to apply the equity perspective to how we measure impacts and gather data, and to strive to design monitoring mechanisms that are inclusive and equitable [ 22 ].

Although helpful in expressing what is meant by an “equity lens,” does it entail that by simply ensuring vulnerable populations are counted, health equity can be achieved? It would be safe to assume that this is not so, but questions such as this one remain around who would be targeted, to what extent, targeted for what, etc. Arguably, this text’s broader focus on identifying priority public health conditions may skew discussions of an “equity lens” to be more pragmatic and focused on methodologies.

On the contrary, the WHO’s Urban HEART was identified as being able to provide an “equity lens” [ 23 ] and more specifically in one instance, in “policy-making and resource allocation decisions” [ 24 ]. Through Urban HEART’s actionable identification and mapping of health inequities, it perhaps fulfills this aim. However, Urban HEART’s identification of implications for governments adopting a “health equity lens” entailed “governments will adopt a health equity lens when planning resource allocation” [ 24 ]. This application of a “health equity lens” similarly leaves questions unanswered (e.g., is this lens always in reference to resource allocation? What steps should be taken in allocating resources to maximize health equity?).

Other instances of unclear language include indicating that “health equity can be considered as a reliable way to measure and monitor how well a city is meeting the needs of its residents” [ 25 ] and “epidemiology and research to add … an equity dimension” [ 22 ], but how this may be determined in practice remains vague. An example of this is provided in the report by the CSDH: “Health equity impact assessment is one of the tools recommended by the Commission … to help decision-makers to systematically assess the potential impact of policies, programmes, projects, or proposals on health equity in a given population with the aim of maximizing the positive health equity benefits and minimizing the potential adverse effects on health equity” [ 2 ]. For instance, how can positive health equity benefits be maximized when understandings of ideal health equity outcomes may vary across stakeholders (e.g., improve those within the bottom fifth wealth quintile vs. improve the health of all in a given community [ 47 ])?

Thus, vague language like “implementing pro-equity policy and planning” [ 25 ], “tak[ing] into account health equity” [ 2 ], and “integrat[ing] equity, as a priority within health systems, as well as in the design and delivery of health services and public health programmes” [ 26 ] is limited in its ability to guide practice without further details on what striving for health equity means or looks like.

To improve public policymaking, clear operational definitions are required to ensure that objectives, targets, and priorities can be established and, accordingly, to assess progress [ 44 ]. Most obviously, this relates to the interchanged use of health “inequities” and “inequalities” in WHO texts, which was finding (iii) noted alongside other findings in Table  2 . Without the acceptance of globally appropriate definitions, operationalizing action on health inequities can be unclear and objectives will vary depending on the parties involved. Moving beyond setting objectives, the varying discourses around health equity can also shift action accordingly. By critically assessing discourses, we can challenge current views, norms, and operations that are held by individuals in policy and practice. In taking the unwillingness to name causes of causes as an example, work is shifted away from addressing fundamental issues. Similarly, in targeting health inequity throughout the life-course, rather than intergenerationally, sought actions will inevitably differ. This is particularly noteworthy when considering how the policy objectives of large, multilateral global health organizations, such as the WHO, differ from member state priorities in recent years, where the latter tend to be shorter-term priorities [ 48 ]. As another example, instead of discussing applying an “equity lens,” what this entails can be described at the outset. This novel study may also guide scholarship to examine other organizations’ work more critically. As noted by Sen [ 49 ], considering the concept of health equity can lead to questions and perspectives that work to enrich the abstractness of equity in general. Thus, this work paves the way for further inquiry into the operationalization of complex key terms or those with embedded values.

Limitations

Although this study was not designed to define health equity and determine how to best act on it, it does seek to uncover the multiple discourses embedded in WHO texts to shed light on how these may result in differing actions. However, one potential limitation arises from the ability of the selected texts to represent the WHO as a singular, monolithic, or unitary organization. For instance, texts produced by headquarters may not necessarily reflect the views or positions of all WHO regions—with note that these analyzed texts are all in English—or result in regions accordingly following through with associated practices. Regions may take their own direction on work, reflecting the differing sociopolitical contexts in which they operate, with one example being the WHO Regional Office for Europe undertaking the “Inequalities in health system performance and social determinants in Europe—tools for assessment and information sharing” project with the European Commission [ 50 ]. Although out of scope for this study, investigations are warranted into assessing how conceptualizations of health equity differ across specific regions; programmatic areas, such as Healthy Cities, in addition to less health equity-imbued areas, such as the “big three” [ 51 ] and perhaps “big four” with COVID-19; and the World Health Assembly’s workings as the decision-making body of the WHO. Similarly, because individuals are responsible for writing texts, it may be difficult to ascertain if ideas are associated solely with the author(s) or reflect the views of the broader organization or organizations responsible for the report(s) (e.g., attributable to the WHO and/or UN-Habitat for two joint reports in the study). Although all texts included in this study are WHO texts, further information on each texts’ respective author information is specified in Additional file  1 . However, with respect to this potential limitation, it is noteworthy to consider that individuals’ views reflected in these texts devise broader WHO policy and practice [ 14 ]. And similarly, institutions follow select actions by way of their individual actors [ 14 ]. Therefore, although this may be considered a limitation by some, it is important to recognize that individuals inherently constitute organizations and the ways in which they operate. In addition, these texts are largely interrelated, as demonstrated in Fig.  1 . Irrespectively, whether the text can be attributed to individual authors or the WHO more broadly, it is noteworthy that these texts shape broader global policy and practice.

As far as we are aware, our study is the first to assess empirically how the WHO approaches health equity. Our findings are an important first step toward addressing this critical gap in knowledge [ 52 ] for policymaking and scholarship. Our aim is to go beyond earlier efforts, including the CSDH’s final report, which some critiqued for its limited policy guidance and over-emphasis on problems as opposed to solutions [ 53 ]. These findings therefore can be applied by the WHO in planning, implementing, and evaluating initiatives, particularly when considering the wide applicability across numerous vertical programs in global health, which are also prioritized by member states [ 48 ]. These findings also have implications for policy and program work more broadly outside of the WHO.

Despite the WHO and UN-Habitat identifying a “prerequisite to action” as “developing a common vision for health and health equity” [ 25 ], at present, this appears to be missing within select WHO texts, as demonstrated in this study, and among WHO actors involved in Urban HEART [ 54 ]. This may be partially attributable to health equity being a “relatively new concern and … not universally applied in public health practice as an operational concept” [ 21 ]. However, with ongoing WHO commitments to “improving the health and well-being of all” (e.g., Fifth Health Sector Directors’ Policy and Planning Meeting for the WHO African Region [ 55 ]) and desire to “integrate equity, as a priority within health systems, as well as in the design and delivery of health services and public health programmes” [ 26 ], what that means and what it could look like needs to be further interrogated. This is particularly important within the context of the COVID-19 pandemic. COVID-19 has afforded lessons in policy development, including moving away from short-sighted solutions to ensuring policy is strategic and focused on equity [ 56 ]. Thus, this opportunity to pinpoint what health in/equity means and how it can be acted on in the long term can be seized, given that COVID-19 may provide an opportunity to refocus on the SDH and health equity [ 57 ]. As such, the results of this study should be utilized to consider what health equity entails in global and public health and policy work and drawn on in determining appropriate courses of action.

Availability of data and materials

All data analyzed during this study are listed in this published article in Table  1 .

Abbreviations

Commission on the Social Determinants of Health

Social determinants of health

Urban Health Equity Assessment and Response Tool

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Amri, M., Enright, T., O’Campo, P. et al. Health promotion, the social determinants of health, and urban health: what does a critical discourse analysis of World Health Organization texts reveal about health equity?. BMC Global Public Health 1 , 25 (2023). https://doi.org/10.1186/s44263-023-00023-4

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Evaluating the performance of health promotion interventions

Manmeet kaur.

School of Public Health Department of Community Medicine Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India

Shankar Prinja

Rajesh kumar.

Health education has been recognized world over as an effective approach for achieving disease prevention and health promotion. Several information, education and communication (IEC) campaigns have been conducted in India. Large sections of population now use contraceptive methods, vaccines, deliver babies in health institutions, adhere to TB medicines, and follow safe sexual practices. Substantial declines in fertility and mortality have also occurred 1 . But lot more remains to be done, especially in view of the emerging and re-emerging communicable diseases and the rising tide of non-communicable diseases.

The potential of health education for behaviour change needs to be harnessed. It has not yet received due policy attention and adequate budgetary allocations in India, despite the fact that Health Survey and Development Committee had devoted a full chapter to it in its report submitted to government of India in 1946 2 . In the first Five Year Plan, on recommendation of the Planning Commission of India, Health Education Bureaus were established in the Centre and States. Later, the State Health Education Bureaus were integrated with the Directorates of Health Services 3 . In the absence of proper staff, equipment, and finances, these bureaus could not play a significant role in strengthening health education in India. Very few institutions/universities conduct professional courses on health education, and only a few studies have addressed the core issue of health education - why and how people change their behaviour?

In this issue Panda et al 4 have argued that preventive care awareness campaign among women's self-help groups by a community health insurance programme, achieved better behaviours in selected rural communities of Uttar Pradesh and Bihar where healthcare indicators are quite low. Improvements in the ‘practices’ were reported for waterborne, airborne and vector-borne diseases. In health education trials, the changes in awareness and practices are usually measured in pre- and post-design periods since having a control population for comparison is generally considered unethical. In such a situation, the total dependence on ‘self-reported’ practices as an outcome measure is problematic since social desirability bias may exaggerate the effects 5 . Hence, objective measures of outcomes should be considered such as observation of the practices or risk factors, disease or death rates.

Health education intervention trials are more complex in comparison to the clinical trials. Often, these need to be conducted at community level rather than at individual level especially when mass media is used. The health education campaigns may use radio, television, print or social media covering large populations. Comparatively longer lead time periods are often needed for sustainability of behaviour change to yield sufficient outcomes or impacts. Therefore, evaluation of health education interventions should consider logical framework by comprehensively measuring the inputs, processes, outputs, outcomes and impacts over a longer time horizon since in the absence of ‘control’ population, it is difficult to establish the cause and effect relationship 6 . Other analytical designs such as interrupted time series and propensity score matched analysis can add strength for attribution of causality to the observed association 7 , 8 . Comparing health education interventions of variable intensity could also be of help for conducting dose-response analysis to understand the cause-effect relationship. A step-wedge design or phased implementation of intervention in various geographic units can also be justified, especially when limited resources are available in the beginning which are likely to increase over time 9 . To understand the processes of behaviour change, qualitative assessments should also be considered along with the quantitative assessment.

Programme evaluation in itself is a difficult endeavour, especially so when it involves evaluation of behaviour change. It requires not only conceptual understanding of the behaviour change principles, but the context also needs to be factored in while applying behaviour change models in various settings. It is equally important to state the behaviour change approach clearly while planning health promotion intervention. Earlier, behaviour change used to be viewed as a linear process starting with awareness, acquisition of knowledge, and then leading to changes in the attitudes and practices, finally culminating into reduction in risk factors, morbidity and mortality. Several theories of behaviour change have now established that social, cultural, political, and economic policies also play an important role in creating an enabling environment for behaviour change. Hence, health promoting policy changes are also required for health education to be successful 10 . Some of the preventive actions would require more support from the community to have desired impact, for example, vector control, water supply, sanitation, air quality, etc . than the others such as safe sex, and personal hygiene.

Community-based organisations such as women's self-help groups could engage with local policy makers, programme managers, and service providers to create enabling environments for encouraging the desired behaviour change. However, considering the current status of women, especially in north Indian rural settings where they have limited mobility, little say in decision making, and very little control over resources 11 ; their empowerment is needed so that they can play a significant role in health promotion. Policy changes at national and international levels are also required for disease prevention. Modern approaches have moved on from health education to health promotion wherein the behaviour change communication is targeted at policy makers as well as community members so that health promoting policies are implemented to create enabling environments in which adopting healthy behaviours becomes more affordable and easier choice for the people 12 .

Legislation and regulations, cash incentives, demand side financing, and insurance plans have also been used as instruments for changing the behaviours of health providers and their clients with variable success. Health insurance has often been advocated as a panacea for addressing myriad problems which health systems are facing around the world today including the issues related to disease prevention and health promotion. In developing countries, various types of insurance, especially the social insurance or community-based health insurance, have been advocated for financing the health services considering that tax-based resources are not enough. Many publicly financed health insurance schemes have been introduced in India such as Rashtriya Swashthya Bima Yojana (RSBY). Health insurance coverage has increased rapidly in the last decade. Now more than 300 million people have some kind of health insurance in India 13 .

Since the providers in a health insurance system are paid for every episode of curative care delivered, it introduces perverse incentive to supply more than desired levels of care, which ultimately drives up the cost of care 14 . As a result, overall health system becomes inefficient, as higher payments are to be paid for the same or even lower levels of health status. If insurance plans can play a role in prevention of disease and promotion of health, some of these shortcomings perhaps can be overcome. However, in view of the weak governance structures in India, insurance-based health system will not be able to address the health problems that are likely to be faced in future.

How are the health care providers paid? This is one of the financing instruments which can create incentives for insurance systems to invest in prevention and health promotion. By paying the health care providers using capitation method, providers can be driven to ensure that population under cover remains healthy. This can maximize their earnings. As a result, providers may engage in health promotion, risk reduction and early detection of disease through screening which is an efficient way of allotting scarce resources. This is evident in the United Kingdom's National Health Service, where primary care trusts are paid on capitation basis 15 . The health education campaign as reported by Panda et al 4 in this issue also indicates that community-based health insurance (CBHI) can incorporate disease prevention and health promotion models. However, sustaining CBHI, especially in the absence of institutional support, is a challenging task 16 . Considering poor paying capacity of millions of poor people in India, the role of health insurance models in health promotion is likely to be limited.

In conclusion, the government should strengthen health promotion by allocating more resources to academic and research programmes which have focus on health promotion. The role of all stakeholders should also be considered along with socio-economic factors while planning or evaluating health promotion interventions. Careful evaluation of health promotion interventions should be conducted before scaling up. The classical randomized control trial (RCT) design may not always be feasible for testing effectiveness of health promotion interventions, hence, alternate study designs which are robust and are easy to implement in developing country setting are needed. The infusion of social science research methodology could enrich health promotion science. Multi-level analysis can take into consideration the individual level and community contexts 17 .

Several low cost health promotion innovations which can be sustained by community-based local organisations need to be tested using robust scientific methods. Health promotion and education have been accorded a priority in the draft national health policy 18 . Health and wellness centres have been proposed at community level. Let us hope adequate resources are allocated to make these centres functional in near future.

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Introduction, health promotion, schools and qualitative research, critical pedagogy and health promotion, acknowledgements.

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Critical health promotion and education—a new research challenge

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Kirk Simpson, Ruth Freeman, Critical health promotion and education—a new research challenge, Health Education Research , Volume 19, Issue 3, 1 June 2004, Pages 340–348, https://doi.org/10.1093/her/cyg049

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In relation to health promotion and education, the use of post‐positivist and constructivist approaches has been gathering strength in recent years. Despite this emerging tradition, little has been done to explore what this sort of approach actually represents, particularly in terms of health promotion in schools, professional organizations and wider society. Acknowledging this, it is suggested that more researchers in this area should be adopting qualitative approaches—including semi‐structured interviews, focus groups, story/dialogue workshops and developmental schemes of health education—in order to uncover the hidden meaning of ‘health promotion’, particularly in the school context. This paper therefore attempts to challenge the idea that traditionalist paradigms of positivist research are capable of appropriately representing the nature and complexity of the health promotion issues. In this paper, methodological and theoretical frameworks that can enable researchers to understand health promotion from the perspective of students, teachers and school ‘stakeholders’ are suggested. Particular attention is given to a discussion of the potential value of designing and implementing programmes of health education or promotion using a critical pedagogical approach within schools in the UK. It is argued that programmes using a critical pedagogical and reflective approach, and which are aimed at social transformation, would be of enormous benefit to both researchers and educational/health professionals who are seeking to understand the complexity of health promotion issues from the perspective of children and adolescents.

In relation to health promotion and education, the use of post‐positivist and constructivist approaches has been gathering strength in recent years. Despite this emerging tradition, little has been done to explore what this sort of approach actually represents, particularly in terms of health promotion in schools, professional organizations and wider society. Acknowledging this, it is suggested that more researchers in this area should be adopting qualitative approaches, including semi‐structured interviews, focus groups, story/dialogue workshops and developmental schemes of health education, in order to uncover the hidden meaning of ‘health promotion’, particularly in the school context. This paper, therefore, attempts to challenge the idea that traditionalist paradigms of positivist research are capable of appropriately representing the nature and complexity of the health promotion issues. In this paper, methodological and theoretical frameworks that can enable researchers to understand health promotion from the perspective of students, teachers and school ‘stakeholders’ are suggested. Particular attention is given to a discussion of the potential value of designing and implementing programmes of health education or promotion using a critical pedagogical approach within schools in the UK. It is argued that programmes using a critical pedagogical and reflective approach, and which are aimed at social transformation, would be of enormous benefit to both researchers and educational/health professionals who are seeking to understand the complexity of health promotion issues from the perspective of children and adolescents.

This paper attempts to challenge the idea that traditionalist paradigms of positivist research are capable of appropriately representing the nature and complexity of health promotion issues. The paper argues for the use of qualitative methodological strategies with particular emphasis on programmes of health promotion that use critical pedagogy, in primary and post‐primary schools in the UK, that can facilitate informed critical debate and discussion aimed at social transformation.

Invariably, schools have become the focus of those charged with positively altering the health culture in the UK. It is hoped by policy makers at both the micro and macro level that a strong process of socialization in regard to healthy eating habits and positive health‐related behaviours will result in the production of a generation dedicated to maintaining the general well‐being of their society (Department for Education and Employment, 1997). Whilst this might be an ostensibly laudable aim, it is a naive and narrow approach that fails to negotiate the gap between policy and practice, and the chasm between normative claims to knowledge and genuine understanding. Many educationalists now readily accept that the critical pedagogical approach of Freire ( Freire, 1970 ), Bruner ( Bruner, 1996 ) and Gardner ( Gardner, 1999 ) is the key to unlocking the potential of school students. Bruner ( Bruner, 1996 ) has been pragmatic in accepting that despite all of the innovation in teaching methodology in recent years, the traditionalist paradigm of pedagogy has retained a place in Western educational culture. The introduction of imaginative approaches to teaching, he argued, necessarily involves changing the ‘folk’ pedagogical and psychological theories of teachers. That some teachers have chosen to cling to what they perceive to be the ‘safety’ of the traditionalist didactic methodology is perhaps a reflection of the pressures of examinations and performance tables based on examination results that deny teachers the opportunity to educate students about issues like health promotion. That teachers are judged according to the examination performance of their students is also a cause for regret. It encourages teachers to be unduly cautious in their preparation and delivery of the curriculum, ensuring that they are reluctant to dispose of outmoded methods of instruction. The ‘folk pedagogy’ of didacticism, therefore, is arguably a utilitarian creation better suited to a bygone age, and is now rightly criticized as an ineffectual way of encouraging and developing positive learning and understanding. In addition, the Department for Education and Skills has not included health promotion as one of its educational or research priorities (Department for Education and Skills, 2003).

However, the inclusion of health promotion as a cross‐curricular theme for all school children in the UK indicates that the government has implicitly acknowledged that it is a key area of education that should be addressed within the context of everyday school ‘lessons’. The current ambiguity regarding the treatment of cross‐curricular themes and how they should be ‘taught’ should not deflect from this. Schools are tasked with ensuring that children are given access to the health promotion debate, yet even at the latter stages of post‐primary education this topic is being dealt with in an ineffective way. The pressurized school culture in the UK, reflected in examination league tables and negative media attention towards the teaching profession in general, means that students are not given the room in which to analyse critically the key issues within the health promotion debate. This is because a large amount of emphasis is placed on ‘core’ curricular subjects and cross‐curricular themes are neglected. This results in a largely apathetic approach to health education (as one of the cross‐curricular themes) and makes an investigation of the cultural context in which the health promotion debate is embedded extremely difficult.

In an educative context, there seems to be little awareness in the UK of how effectively schools (at both primary and post‐primary level) are addressing the core objectives of health promotion, either through direct curricular application or through the ‘hidden’ curriculum of the school ethos and approach to education. Although models of ‘experiential learning’ ( Kolb, 1984 ) and ‘reflective practice’ ( Schön, 1983 ) have attained mainstream status and legitimacy, at least in terms of Initial Teacher Education, there seems to be little room for adherence to theoretical paradigms of reflective action within schools. It seems that curricular and examination‐related pressures dominate them instead. It is the task of research to identify potential mechanisms by which critically oriented programmes of health education can achieve credibility within schools.

The National Healthy School Standard was proposed in the UK Government Green Paper Our Healthier Nation in 1998 ( Department for Health, 1998 ). In this paper, the government identified the school as a setting to improve the health of children, and outlined its view that healthy schools are in a key position to improve the health and educational achievement of children and young people. In 1998, the government commissioned eight pilot initiatives in health promotion and education. The initiatives—in Cornwall, Doncaster, Durham and Darlington, Hounslow, Manchester, Norfolk, Staffordshire and City of Stoke on Trent and West Sussex—were limited both in scope and geography. They were envisaged as a means of developing leadership and management skills in Personal, Social and Health Education (PSHE), improving teaching in this area and tackling social exclusion issues. The pilot projects were evaluated externally by the Institute of Education, University of London, using a case study approach. This evaluation process involved interviews with key workers in the pilot sites, education and health professionals, school staff and governors, young people, parents, and those providing support services to schools. The evaluations found that the importance of celebrating achievements in the context of on‐going whole school improvement was crucial to improving the status and credibility of school‐based health promotion initiatives. The evaluations also showed the importance of involving young people at all levels, including those from minority ethnic groups, within health promotion schemes.

A clear role for the national healthy schools team in disseminating best practice and encouraging networking was suggested, in addition to the creation of a national standard that would be adaptable enough to reflect local best practice and meet local needs. Despite the obvious forum for the implementation of these ideas that PSHE provides, little has been done since then to strengthen the position or status of PSHE in the national curriculum or, indeed, to further develop more pilot health promotion projects for implementation throughout the regions of the UK.

The current offering of PSHE in schools has, therefore, done little to reassure health or education professionals that school students are being offered scope for informed discussion of issues central to their development. The fact that statutory provision of PSHE stops for students at the age of 16 emphasizes a lack of government activity in relation to ensuring that those in the post‐compulsory sector are offered opportunities to analyse the personal social and civic components of health promotion. In many ways, there is undoubted crossover (and value) between health promotion and citizenship education for students in the post‐16 sector. Citizenship, despite the recommendations of a government Advisory Group in 2000, remains a neglected feature of the education system for post‐16 students. It may be that the establishment of a critically informed programme of citizenship education provides an ideal opportunity for the exploration of health issues. This would constitute an implicit recognition that the health message is no longer simply specialized technical knowledge, but that it represents a core aspect of cultural, social and political debates. There is a need for qualitative research within schools that seeks to uncover perspectives of health education and promotion that are rooted in the culture and experience of schoolchildren, older school students, parents, teachers and community leaders. Piloting schemes of health education using critical pedagogical methods could serve to provide examples of how such approaches might both raise awareness of the health promotion message and empower disenfranchised sections of the community.

The interpretivist tradition has gathered strength in educational research within the last three decades. Interpretivist educational research has stressed the need to put analyses in context, presenting the interpretations of many, sometimes competing, groups interested in the outcomes of instruction or particular educational programmes, such as health education/promotion. The constructivist aspect of this qualitative research tradition reflects the belief that school students individually and collectively construct reality ( Denzin and Lincoln, 1994 ; Bruner, 1996 ). Proponents of the interpretivist/constructivist paradigm have sharply divergent views about the nature of reality from proponents of the quantitative paradigm. For qualitative researchers ‘truth is a matter of consensus among informed and sophisticated constructors, not correspondence with an objective reality’ [( Lincoln and Guba, 1989 ), p. 44]. Unlike the technical, rational approach of previous positivist perspectives that dominated educational research, the interpretivist approach has been chiefly involved in helping to understand and evaluate change. Despite this movement, the positivist tradition arguably still enjoys strong support in many areas of social and educational research. Indeed, Smeyers and Verhesschen ( Smeyers and Verhesschen, 2001 ) have argued that despite the increasing credibility of qualitative methods in social research circles, the debate between quantitative and qualitative research methods is still very much apparent. They note [( Smeyers and Verhesschen, 2001 ), p. 75] ‘the suspicion is that in some way what is offered by educational or more generally social science research, cannot adequately satisfy the need for solid knowledge’. However, Green and Tones [( Green and Tones, 1999 ), p. 133] have challenged the relevance of positivist research in the context of health promotion and have argued instead for a broader approach to assembling evidence about the effectiveness of health education programmes. Green and Tones ( Green and Tones, 1999 ) have suggested that this broader approach will contribute to the move towards evidence‐based practice within health promotion and education.

It is possible to suggest, however, that the quest for ‘solid knowledge’, in the form of tangible numerical outcomes like school league tables (which the government in the UK has encouraged), has served a dual purpose: (1) it has solidified the position and respectability of positivist research paradigms, and (2) it has ensured that schools have been forced to devote an unprecedented level of energy to curriculum ‘coverage’. This coverage and examination‐related pressure means that teachers have less and less opportunity to engage their students in cross‐curricular health education or meaningful health promoting activities, let alone find the space within a crowded timetable to offer discrete health education classes that employ a critical pedagogical approach.

There is a need to support interpretive qualitative research methodologies, in particular the use of critical pedagogy‐oriented programmes of health promotion, within the UK education system. The interpretive aspects of qualitative research attempt to understand the phenomena of health promotion through the meanings that people (teachers, students, parents, health professionals, community members) assign to them. No matter how firm the empirical basis of positivist methodological approaches that seek to lay claim to ‘objective’ truths, such strategies arguably neglect the potential to explore the competing narratives within health‐promoting schools. Rather, they tend to concentrate on making a series of ‘normative’ claims ( Labonte and Robertson, 1996 ). Interpretive methods should not be discussed using the criteria of positivist research paradigms that have arguably developed out of positivist epistemological ideas. The advantage of interpretive research is its emphasis on the philosophical grounding of methods. From an interpretive perspective, researchers can draw the most valid conclusions by attaining the deepest understanding of the problem in its context.

There is a need for health promotion educative research projects that focus on encouraging high levels of participation and empowerment amongst schools, students, teachers and parents. These types of projects would use critical pedagogy as an intrinsic part of effectively communicating the health promotion message, supporting the objective of creating a teaching and learning environment that fosters cooperative, participative student learning. Discussion‐based programmes of health education would attempt to reconfigure classroom practice in order to place a greater emphasis on student learning and provide a means by which health education could assume a central role in the establishment of school curricula aimed at achieving meaningful understanding of health issues. From a research perspective, researchers could be involved in the design and delivery of such courses—collaborating in the construction of frameworks for the course, evaluating the project by way of non‐participant observation or as participant observers. Concurrent individual and group interviews, combined with other qualitative strategies such as student learning diaries, would further strengthen the rigour of this approach.

The development of the concept of empowerment in health promotion began with the emergence of the community health movement during the 1970s and 1980s. This movement attempted to stem the increasingly powerful flow of authoritarianism and individualism that had begun to dominate the social and political agenda in the UK ( Beattie, 1991 ). Empowerment was identified as a possible solution—encouraging people to educate themselves, and calling for the government to support community groups, both structurally and financially, in their attempts to create change and address health inequalities. The WHO ( WHO, 1986 ) emphasized this idea by acknowledging that health developments in communities should be made not only for the people, but also by the people. Effective learning and the consequent permanent alteration of social behaviour patterns require people to engage in a process of discovery and transformation ( Daloz, 1986 ; Bevis and Watson, 1989 ). As noted by Tones and Tilford ( Tones and Tilford, 1994 ), there has been a development of a more sophisticated approach in relation to educational models within health promotion, which have begun to take account of the importance of the concept of empowerment. These developments have been greatly influenced by child‐centred progressive educational methods.

Currently, however, the UK educational system does not offer students or teachers the opportunity to engage in critical programmes of health education that are oriented towards empowerment. Health promotion has not been afforded discrete curricular status—currently forming only part of a wider PSHE programme. That this PSHE programme itself suffers from a relative lack of credibility emphasizes the marginalization of health promotion, especially within schools that foster a more traditional academic ethos. The PSHE syllabus does not offer widespread opportunity for critically informed debate. As Dadds ( Dadds, 1999 ) noted, the involvement of students in their own pedagogical experiences is essential to the quality provision of education. It would be difficult to suggest that the prescriptive nature of the current syllabus is capable of accommodating an in‐depth critical pedagogical approach to health promotion. Tones and Tilford ( Tones and Tilford, 1994 ) noted that policy makers in the UK have failed to recognize the importance of evaluating a subject (health education) that has had low status within the curriculum.

Educative‐research projects (using critical pedagogy) should be designed and implemented within schools in the UK, to provide working examples of critically oriented health‐promoting practice. Projects of this nature could move away from tightly defined evaluations of prescriptive curricular provision and concentrate on analysing the impact of student‐centred health education, mapping the transformative changes that occur in the participants’ (students and teachers) understanding of health promotion. For teachers and researchers, the value of such programmes in terms of identifying particular pedagogical styles that may contribute to greater understanding of the health debate is obvious. Whilst the WHO has recently placed considerable emphasis on the importance of health promotion within schools, there has not yet emerged a coherent strategy for ensuring that schools become environments in which students and teachers link the goal of health improvement to the imperatives of general schooling. It is possible to argue that the implementation and evaluation of programmes of health promotion in schools, with a critical pedagogical component, would offer a method by which people could begin to unlock the potential for social transformation.

It was Schön ( Schön, 1983 ) who brought the concept of ‘reflection’ into the centre of an understanding of what professionals do. Schön ( Schön, 1983 ) opposed the dominant model of ‘technical‐rationality’ (a positivist epistemology of professional practice) as the basis of all ‘professional knowledge’. Testing out theories and programmes of health promotion would allow both researchers and teachers to develop educational ideas and frameworks that are grounded in the reality of experience. Teachers, students and researchers could write‐up recordings, keep learning diaries, talk things through with supervisors and engage in regular dialogue. This act of reflecting on practice would enable those involved in health promotion in schools to develop sets of questions and ideas about their activities and practice.

Evaluating programmes or schemes of health promotion of this type would be reliant upon gaining access to the worldviews of the participants. This can only be achieved through the utilization of qualitative research methods—in particular the employment of methods like story/dialogue workshops ( Labonte et al. , 1999 ). Nettleton and Bunton argued that:

Health promotion techniques that aim to listen more attentively to the views of lay people, by using qualitative interviews, participant observation or health diaries, penetrate into the lives and mind of subjects. [( Nettleton and Bunton, 1995 ), p. 47]

The story/dialogue method is a qualitative research technique that attempts to create structured group dialogue around case stories that address particular generative themes. The idea of generative themes is congruent with the wider educational principles of the Teaching for Understanding (TfU) model advanced by Gardner and Blyhth ( Gardner and Blythe, 1998 ). In this paradigm, students, teachers and other key actors within the health promotion ‘community’ would be encouraged to articulate their experiences of school‐based initiatives, classroom activity and support networks for the health‐promoting school from their own perspective .

Story/dialogue workshops are a flexible research tool and can vary in size from 20 to over 200 participants. They can vary in length from 1 to 3 full days. As an example, a workshop for teachers could be designed to include at least 1 full day in which smaller story groups (a ‘subgroup’ of usually five to 10 participants) meet to discuss case stories (experiences of health‐promoting programmes and pedagogy) which are based on a generative theme (e.g. ‘The importance of engaging students in their own learning’), using dialogue as a means of assisting the participants in creating theories and models of good practice ( Labonte et al. , 1999 ). This idea of evaluating programmes from the perspectives of the participants is supported by the critical theory approach of both Habermas ( Habermas, 1984 ) and Freire ( Freire, 1970 ). In this context, the story/dialogue groups would be aimed at fostering an ongoing process of social transformation within schools involved in health promotion in the UK. Although originally developed in the field of criminology, the principles of ‘realistic evaluation’, as described by Pawson and Tilley ( Pawson and Tilley, 1997 ), support the idea of new frameworks for assessing the effectiveness of programmes of health promotion. Their approach is also concerned with considering the context, mechanisms and outcomes of particular programmes—in other words ‘what works’, ‘for whom’ and ‘why’. Indeed, they argued that their approach could provide for the production of lessons and schemes that can be appropriately used within the construction and refinement of social policy and practice. Pawson and Tilley ( Pawson and Tilley, 1997 ) noted that it was important that any programmes implemented and evaluated in this way need informed and critical application in regard to the details of particular social and cultural contexts.

There is growing support for the idea that conventional scientific norms—an exclusive focus on quantitative data and the idea of objectivity—are an insufficient way of evaluating health promotion. Indeed, Springett [( Springett, 2001 ), p. 100] has argued for qualitative participatory approaches to health promotion and evaluation that have been designed to empower people and which can be a ‘real catalyst for change’. Participation of this sort means engaging in dialogue at all stages of the research evaluation and shifting power in favour of those being researched. This is in stark contrast to the positivist models of research that have dominated health promotion and evaluation in the past ( Springett, 2001 ). The development of story/dialogue groups as a key part of school‐based, health promotion strategies would be designed to enable teachers and students to make clear their theories and views on health promotion within schools; and to consequently subject these views to peer‐led critical scrutiny. Student story dialogue groups would remove the idea that the evaluation of health promotion programmes is focused solely on the perspectives of ‘adults’ and the students would be encouraged to exchange their opinions in relation to the effectiveness of the health‐promoting school. The overall objective of such groups is to uncover the perspectives of all of the participants, which can then be used to inform the subsequent design of new initiatives or programmes for health‐promoting schools.

Within these suggested programmes of health education/promotion, there is a need to incorporate a critical pedagogical approach. Critical pedagogy is expressed in both content and process. Those interested in applying pedagogical reform to models of health promotion should distance themselves from traditional positivist paradigms of orthodox knowledge transmission and instruction. As noted, within the context of a highly prescriptive and pressurized school curriculum (as in the UK), the room that teachers have for manoeuvre is limited. It is incumbent upon the government to offer schools and communities opportunities to become involved in critical discussion of health promotion issues. The challenge for policy makers and educators involved in health promotion is to encourage school students to become ‘active producers of meaning’ [( Dehler et al. , 2001 ), p. 504]. This should be based, in part, on the diverse experiences of the students, rather than on educational dynamics that make students passive consumers of information. The literature on lay health beliefs has indicated that those involved in health promotion, including school‐based educators, should take account of and be sensitive to the language and the concepts of their intended audience ( Bunton et al. , 1995 ). Indeed, critical pedagogy requires alternative teaching methods that foster dialogue, critical reflection and social transformation. This is not to say that content is unimportant. Indeed, in the context of critical pedagogy, it is possible to argue that content and process are interrelated. Critical pedagogy necessarily involves providing students with access to a range of information and evidence that is relevant to their health‐related discussion and debate. It is then the task of the teachers to facilitate critical analysis of this information (content).

In this way, school students are offered a greater amount of access to health promotion issues, and are encouraged to share their experiences and understanding, resulting in a form of emancipatory learning ( Habermas, 1984 ). Emancipatory learning is not concerned with instrumentalist objectives. Rather, its purpose is to foster and develop understanding and knowledge about the nature and causes of unsatisfactory social, political, cultural and economic circumstances in order that people might create strategies to alter them. Programmes of health promotion aimed at emancipatory learning can help citizens to gain more autonomy and independence, and to bring about change in the interests of equality and social justice.

Programmes of health promotion utilizing a critically informed approach to health promotion within UK schools would undoubtedly contribute to the empowerment of young people, schools, parents and communities. Empowerment, in this context, would represent the ability of school students and teachers to gain greater understanding and control over the personal, social, economic and political factors that directly affect them ( Judd et al. , 2001 ). Programmes of this type would offer much in terms of the ongoing debate within health promotion research, policy and practice. Health promotion programmes are likely to be most effective when they are sensitive to local social and political realties, and when they are embedded within appropriate theoretical, pedagogical and cultural frameworks. For children, including those from socially disadvantaged areas, this could provide not only a greater level of access to important information, but also the potential to increase their awareness and understanding of health promotion. Empowerment strategies using appropriate educational programmes (and using critical pedagogy) and adequate qualitative interpretive research strategies for their evaluation are not separate and independent, but rather are closely and importantly inter‐related. From an educational and health promotion perspective, therefore, the inclusion of critical pedagogical approaches within health promotion curricula and qualitative interpretivist paradigms of research could be considered essential.

The authors acknowledge the financial support provided by the Research and Development Office for the HPSS in Northern Ireland.

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Author notes

1School of Dentistry, Queen’s University, Belfast, UK 2Correspondence to: K. Simpson; e‐mail: k.simpson@queens‐belfast.ac.uk

  • health promotion
  • knowledge acquisition
  • health education

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Characterization of critical health promotion: a scoping review protocol

Affiliations.

  • 1 School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia.
  • 2 Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar.
  • PMID: 37435684
  • DOI: 10.11124/JBIES-23-00008

Objective: This scoping review will explore how critical health promotion is characterized in the health promotion literature.

Introduction: Critical health promotion has emerged as a social justice approach to health promotion to address the persistent global issue of health inequity. Whilst critical health promotion is not conceptually new and the term has been used in the literature, albeit sparingly, this approach has not been adopted as standard health promotion practice, compromising the advancement of health equity. Given that language shapes the understanding and practice of health promotion, it is imperative to explore how critical health promotion is characterized in the literature to increase uptake of the approach.

Inclusion criteria: This review will consider sources that explore critical health promotion and are explicitly positioned as health promotion sources.

Methods: Scopus, CINAHL (EBSCOhost), PubMed, Global Health (CABI), and the Public Health Database (ProQuest) will be searched to identify relevant full-text papers, including original research, reviews, editorials, and opinion papers. Searches of Google Scholar, Google, and ProQuest Dissertations & Theses Global (ProQuest) will be undertaken to identify gray literature. No language or date restrictions will be applied. Two reviewers will screen sources and extract data using a tool that will be pilot tested, modified, and revised, as necessary. Analysis will involve basic frequency counts and descriptive qualitative content analysis through basic coding. The results will be presented in tables, charts, and word clouds, accompanied by a narrative summary.

Copyright © 2023 JBI.

  • Databases, Factual
  • Health Promotion*
  • Review Literature as Topic*

Developing Leadership for Health Promotion Essay

Introduction.

The main goal of public health practitioners is to promote the health and wellbeing of individuals and communities. To attain it, they must be able to collaborate with interdisciplinary professionals, communicate with people from diverse backgrounds, and inspire them for action. They must have critical thinking skills to identify needs for change and then be able to mobilize available resources for its implementation. For this reason, public health practitioners must possess leadership qualities and competencies and adhere to effective Leadership and change management models that would help them to direct and empower others successfully. Thus, the present paper will discuss the importance of traditional leadership and change leadership. Initially, these two concepts will be defined, and, consequently, different Leadership and change management models will be critically evaluated. Lastly, leaders’ roles in the delivery of health promotion programs will be described to conclude the discussion.

There are a plethora of different definitions of Leadership that may capture distinct leader roles, functions, and abilities. The main ones include guidance, influence, inspiration, support, responsiveness to others’ needs, development of a shared direction and vision (Moodie 2016). As for Leadership in public health, Moodie (2016) defines it as maximizing personal potential, as well as the sense of personal worth and meaning, along with maximizing “the potential of others and the sense of worth and meaning they draw from their lives” (p. 679). This take on Leadership implies that a successful leader can align individual preferences and interests with organizational or public health needs and goals and influence stakeholders to adopt values, beliefs, and behaviors needed to attain the desired objectives. As noted by Hao and Yazdanifard (2015), in the business environment, these leadership functions are crucial for attaining sustainable growth, increasing competitiveness and innovation, and motivating subordinates to commit to their jobs. Similarly, Leadership in public health motivates stakeholders to accept and take a proactive stance on any proposed public policy change and other initiatives aimed at improving public wellbeing and quality of life.

Change and Change Leadership

Change is an intrinsic element of human lives and is part of every field of performance, including healthcare. It may be regarded as the modification of specific states of being and behavioral adaptation to evolving environmental demands and trends. Although changes may take many shapes and forms, they often share a common characteristic: they induce a certain degree of discomfort and stress since they require one to alter the way they usually act, think and look at things (Hao & Yazdanifard 2015). For this reason, people may be resistant to changes, especially when those changes affect long-established modes of behavior.

Change leadership is meant to minimize resistance to change and mobilize resources needed to attain it more smoothly and successfully. Change leadership incorporates the characteristics of traditional Leadership discussed above with a minor difference in focus. According to Gill (2003), specific tasks involved in change leadership are the creation of a vision for change, promotion of supportive values and culture, strategic planning and analysis, stakeholder empowerment, motivation, and inspiration. This leadership model, which primarily works with the psychological and emotional aspects of human performance and emphasizes the importance of communication, can help to eliminate all possible obstacles to change and also design an efficient management approach.

Leadership and Change Management Models: Critical Analysis

Models of leadership.

In this section of the paper, two leadership models – action-centered Leadership and Situational Leadership – will be discussed and compared. The former model was created by John Adair in 1986 and incorporated three basic elements: 1) achieving the task, 2) maintaining the team, and 3) meeting individual needs (Williams 2005). The first one includes such activities as planning and monitoring; the second one comprises conflict management, team building, and other practices aimed at team coordination (Williams 2005). The third element – accountability of individual needs – requires the provision of feedback and support to an individual involved in a certain endeavor (Williams 2005). In accordance with the action-centered leadership model, the main role of a leader is to keep a proper balance between these three aspects of organizational performance.

The situational leadership model was created by Paul Hersey and Ken Blanchard in 1977. It is more specific than Adair’s model in terms of advising leaders on how to choose leadership styles depending on employee characteristics. According to Williams (2005), subordinates’ “functional maturity” serves as the primary determinant of leadership style in this model, and it refers to their ability to perform tasks independently and effectively, as well as their level of commitment and motivation to work (p. 33). For instance, when all employees are competent and engaged, one should apply the delegating leadership style that is characterized by a high level of empowerment and work autonomy. Conversely, when employees do not have the necessary competencies, greater control should be imposed on them by leaders.

Overall, Adair’s model proposes an integrative and highly engaged leadership approach, which may be considered its main strength. It is valid to say that it combines the features of both transactional and transformational Leadership since it is both task-oriented and people-oriented. It means that when using this model right, one will be able to increase individuals’ motivation and satisfaction with work by taking into account their interests and increase productive outputs of the team by aligning members’ personal objectives with the organizational ones.

At the same time, situational Leadership implies a more substantial degree of flexibility and adaptability, which can be considered the major model’s strength. However, its weakness is insufficient consideration of other factors affecting a person’s performance besides their level of skill and knowledge. While it suggests that the provision of psycho-emotional support helps to motivate employees better, it does not take into account other factors that may affect one’s commitment. According to Lee and Raschke (2016), psychological safety, self-actualization, ability to meet personal needs and interests are among those factors. Based on this, Adair’s model may be more successful in motivating subordinates as it focuses on such an extrinsic factor as team relationships and also pays greater attention to individuals.

Regardless of the discussed weaknesses and differences, both situational Leadership and action-centered Leadership can be used by leaders as guides during the development of necessary competencies. It is clear that these two models require a leader to have extensive knowledge of how to direct activities, coach, and encourage individuals. Nevertheless, they do not offer exhaustively full answers on how to do that. Thus, one will have to conduct additional research to apply the ideas proposed by Adair, Hersey, and Blanchard well.

Change Leadership Models

Two of the models that can be utilized to lead changes in organizations, as well as projects, service systems, and public health programs, are Lewin’s three-stage model and Beckhard’s change program. The first one includes such steps as unfreezing, changing, and refreezing, which refer to “altering the present stable equilibrium which supports existing behaviors and attitudes,” developing new procedures and rules, and “stabilizing the change by introducing the new responses into the personalities of those concerned” (Brisson-Banks 2010, p. 244). The model developed by Beckhard comprises the following phases: 1) goal setting and development of a vision of a desired future state, 2) diagnosis of present conditions, 3) definition of a transition state and formulation of short-term objectives, and 4) design of strategies and action plans to manage the change (Brisson-Banks 2010). Both of the models imply an extensive analysis of environmental trends and an understanding of the goals that should be attained.

It is valid to say that Lewin’s model is stronger in terms of eliminating psychological obstacles to change, such as individuals’ resistance due to high perceived risks or unwillingness to alter habitual ways of behavior. This model focuses on culture-creating and value-adding activities, as well as communication of a need for change, vision, mission, and other things that may inspire stakeholders to commit to the process of change. It is observed that when the elements of organizational culture are aligned with employees’ personal values, they become more willing to work toward the achievement of organizational goals (Suwaryo, Daryanto & Maulana 2015). Moreover, the manner in which a leader communicates with subordinates, the clarity of objectives, and need for communication, and the efforts to build trust with the team are also crucial for the smooth execution of planned change programs (Suwaryo, Daryanto & Maulana 2015). Since Lewin’s model captures all of these aspects, its application can be particularly beneficial when there is a need to instill greater motivation.

At the same time, Beckhard’s program seems to be more task-oriented. It does not specify that stakeholders’ attitudes should be changed in order to foster change, yet it does not exclude an element of people-orientedness either. Overall, it proposes which steps must be undertaken but provides leaders and managers with the freedom to choose specific activities. Therefore, the success of its implementation will largely depend on leaders’ background knowledge and competence.

Leadership Roles in Delivering Community-Based Health Promotion Programmes

In order to initiate community-based health promotion programs and bring them to success, it is pivotal to ensure a high level of community participation and develop partnerships (Hunter 2009). Moreover, wellbeing promotion normally requires changes in behaviors and views, as well as existing health systems. Leaders can play a crucial role in fulfilling both of these aspects by performing such functions as the analysis of needs, vision creation, development of strategies aimed at minimizing risks, and allocating resources optimally. The main leader task in health promotion is probably the involvement of different stakeholder groups in intended initiatives by identifying why they may resist change and then addressing their fears and other psychological barriers by drawing on high-quality evidence and demonstrating possible benefits of their engagement in health promotion and change. Through communication, leaders can establish program credibility, build trust with different stakeholders and gain their support, which, along with the overall implementation strategy, can substantially define the outcomes of any planned endeavor.

Leadership determines the way any project and initiative are administered and can often determine stakeholders’ willingness and desire to spend their time and efforts on health promotion and change. In the present-day environment, no organization or program can avoid difficulties and barriers to better performance. While bad Leadership would fail to eliminate them, good Leadership will not only eliminate them successfully but also strive to prevent their occurrence. Excellent Leadership always finds the right balance between strategic tasks, individual needs of those involved, and overall organizational/project needs. Moreover, it concentrates on communication, the creation of a shared vision, the dissemination of information, and the promotion of values. Thus, good leaders are capable of addressing the very core of human motivation and inspire others to participate in public health improvement.

Reference List

Brisson‐Banks, CV 2010, ‘Managing change and transitions: a comparison of different models and their commonalities,’ Library Management , vol. 31, no. 4/5, pp. 241-252.

Gill, R 2003, ‘Change management – or change leadership?’, Journal of Change Management , vol. 3, no. 4, pp. 307-318.

Hao, MJ & Yazdanifard, R 2015, ‘How effective leadership can facilitate change in organizations through improvement and innovation,’ Global Journal of Management and Business Research: Administration and Management , vol. 15, no. 9, pp. 1-5.

Hunter, DJ 2009, ‘Leading for health and wellbeing: the need for a new paradigm,’ Journal of Public Health , vol. 31, no. 2, pp. 202-204.

Lee, MT & Raschke, RL 2016, ‘Understanding employee motivation and organizational performance: arguments for a set-theoretic approach, Journal of Innovation & Knowledge , vol. 1, no. 3, pp. 162-169.

Moodie, R 2016, ‘Learning about self: leadership skills for public health’, Journal of Public Health Research , vol. 5, no. 1, p. 679.

Suwaryo, J, Daryanto, HK & Maulana, A 2016, ‘Organizational culture change and its effect on change readiness through organizational commitment’, International Journal of Administrative Science and Organization , vol. 22, no. 1, pp. 68-78.

Williams, M 2005, Leadership for leaders , Thorogood, London.

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