THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Number 1, 2006

Philosophical Reections on Health Education

and Health Promotion:
Shifting Sands and Ebbing Tides
Thomas ORourke
Abstract
Philosophy, which plays an important role in any feld,
continually evolves. The purpose oI this paper is to describe
and critique several oI the major shiIts in health education
philosophy over the past century and suggest the potential
merits oI an expanded macro philosophy. It is doubtIul that
our present health education philosophy, with its emphasis
on improving health through individual behavior and liIestyle
modifcation, is suIfcient. Its Iocus is narrow and prevents us
Irom considering more eIIective and eIfcient approaches in
health education and health promotion. The outcomes oI this
tunnel philosophy are a less caring and healthy society and a
narrow, less eIIective health education agenda. A change in
philosophy is essential to maximize opportunities for a more
healthIul society on individual and community levels. This
paper also presents Ior consideration several other philoso-
phies that may provide additional insights to contemporary
health education philosophies.
Introduction
Philosophy may be defned as 'a statement summarizing
the attitudes, principles, belieIs, values, and concepts held
by an individual or a group (Cottrell, Girvan, & McKen-
zie, 2006, p. 77). Philosophy plays an important role in any
feld, be it health, medicine, politics, or economics, and it
continually evolves. Most felds will be infuenced by several
philosophies, some more dominant than others at any given
time. Sometimes, new philosophies emerge and Iorgotten
or dismissed philosophies are rediscovered. In any event,
philosophy guides thoughts, perceptions, and activities in
health education.
The purpose oI this paper is to describe and critique
several oI the major shiIts in health education philosophy
over the past century and suggest the potential merits oI an
expanded macro philosophy. This paper also presents Ior
consideration several other philosophies that go beyond the
existing dominant health education philosophies oI the past
century. These philosophies may provide additional insights
to contemporary health education philosophies.

The Changing Landscape
Throughout the past century, the import and use oI various
philosophies has changed. In the early part oI the last century,
health education Iocused on personal hygiene and communi-
cable diseases (Regney, 1922). Much oI health education was
cognitive-based and many health educators emphasized Iac-
tual learning. As many communicable diseases were brought
under control and longevity dramatically increased, the
importance oI chronic diseases, or 'diseases oI civilization,
such as heart disease, cancer, and stroke emerged. Later in
the last century, the Iocus shiIted Irom diseases to behaviors
considered responsible Ior the diseases. This change in Iocus
was highlighted by several events that led to and resulted in
the predominance oI the behavior change health education
philosophy emphasizing an individual (micro) perspective.
The frst event was the 1979 publication oI Healthy People:
The Surgeon General`s Report On Health Promotion and
Disease Prevention (U.S. Department oI Health Education
and WelIare, 1979). In the Iorward, Joseph CaliIano, acting
Secretary oI the Department oI Health Education and WelIare,
stated, 'You, the individual, can do more Ior your own health
and well-being than any doctor, any hospital, any drug, any
exotic medical device (p. viii). This IorceIul statement was
based on a group oI American experts that suggested that
perhaps 'as much as halI oI U.S. mortality in 1976 was due
to unhealthy behavior or lifestyle; 20 % to environmental
Iactors; 20 to human biological Iactors; and only 10 to
inadequacies in health care (p. 9).
The second event was the Reagan era. Even though the
emphasis on individual responsibility was initiated during
the previous Carter administration, the Reagan era had a
deep impact on the philosophy oI health education and
health promotion (Allegrante, 1986). The notion oI health
as a collective responsibility was replaced by an emphasis
on social Darwinism, where individual responsibility and
initiative prevailed. As Beauchamp (1984) clearly stated,
'.the norm oI market justice is still dominant and the
primary duty to avert disease and injury still rests with the
individual. The individual is ultimately alone in his
or her struggle against death (p. 308). Not only was col-
lective responsibility downplayed by the government, but
the government also was Irequently portrayed as a source
of problems or, at least,
Page 8 THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Num-
an obstacle to a more responsible and productive citizenry
and society. The importance oI individual responsibility
was emphasized by Iormer Secretary oI Health and Human
Services, Louis Sullivan (1990), who stated:
For the harsh truth is that a high percentage oI the dis-
ease and disability aIIlicting the American
people is a conse- quence oI unwise choices oI
behavior and liIestyle. Those poor choices
result in lives that are blighted, stunted, and l e s s
Iulflling, and they cause an unnecessary, costly drain
on the resources available Ior health care. (p. 2)
The Trilogy
Not surprisingly, the micro behavioral change philosophy
oI the late 1970s and early 1980s gave rise to Promoting
Health/Preventing Disease: Objectives Ior the Nation (U.S.
Department oI Health and Human Services |USDHHS|,
1980) and Healthy People: Health Objectives oI the Na-
tion 2000 |USDHHS, 1990| and 2010 |USDHHS, 2000|.
During the 1990s, another stimulus Ior a micro behavioral
change Iocus was the seminal publication, 'Real Causes oI
Death by McGinnis and Foege (1993). The authors oI this
publication contrasted the previous perspective oI viewing
the leading causes oI death, such as heart disease, cancer,
and stroke, to a perspective that highlighted the number oI
deaths attributable to tobacco, poor diet, physical inactivity,
motor vehicles, frearms, sexual behavior, and other be-
haviors. These publications redefned the concept oI health
promotion to that oI health improvement through individual
responsibility and personal behaviors. A review oI several
hundred objectives outlined in the Healthy People documents
reveals much less awareness to improving health through
government involvement in the area oI health protection or
collective responsibility Ior its citizenry. With an emphasis
on empowerment and selI-interest, the government Iailed
to adequately acknowledge the economic, political, and
environmental Iorces that infuence and reinIorce unhealthy
behaviors. As such, health promotion underwent a transition
Irom the classic defnition Iorwarded by Siegrist (1946):
'Health is promoted by providing a decent standard oI liv-
ing, good labor conditions, education, physical culture, and
means oI rest and relaxation. (p. 127).
In essence, Healthy People (U.S. Public Health Services,
1979) and the subsequent trilogy (USDHHS 1980, 1990 and
2000) instituted parameters by redefning health promotion
Irom a broad perspective to a narrow concept encompass-
ing liIestyle modifcation with an emphasis on individual
responsibility. This redefnition was not a minor philosophi-
cal change; it had a major impact on the concepts oI health
education and health promotion, the types oI activities and
programs Iunded, the research activities conducted, and the
missions oI proIessional preparation programs. This transi-
tion did not occur without criticism and debate (Allegrante,
portance oI individual responsibility and personal behavior,
O`Rourke (1989) labeled this paradigm shiIt as 'micro-myo-
pia and highlighted two signifcant negative implications:
(1) it Iocused health promotion eIIorts inwardly, thus com-
promising support Ior population approaches at the collective
community/societal level; and (2) it laid an ideal groundwork
Ior 'victim blaming, while defecting societal responsibility.
Allegrante and Green (1981) noted:
One danger oI such a policy is that the Iederal govern-
ment will abrogate its responsibility to provide the social
and economic supports Ior necessary organizational and
environmental changes. . . . Education oI the public is an
essential component (and perhaps the most important
component) oI a national program to strengthen behav-
ior conducive to health. But without the
organizational, eco- nomic, and
environmental supports for such behavior, health
education will appear to be government propaganda
a smoke screen to cover the cuts in health services and
the proposed regulatory reIorms. (p. 1529)
The emphasis on individual responsibility coupled with
the lack oI governmental response Ior health promotion
reinIorced what O`Rourke (1989) called the 'emerging mo-
rality oI health behavior. That is, the use oI stigmatic labels
to describe health behaviors became commonplace. Obese
people were labeled as weak, inactive people as lazy, smok-
ers as selI-indulgent, and AIDS victims as immoral and/or
worthy oI their plight.
The Macro Perspective
The philosophical pendulum continues to Iocus on risk tak-
ing with risk imposing a blink on the radar screen oI thought,
debate, and scientifc inquiry. The past and present Iocus oI
health promotion is on the individual to reduce smoking,
improve diet, and increase physical activity. There remains
Iar less Iocus or discussion on societal policies in the area oI
health promotion such as mandating physical activity pro-
grams in schools, increasing incentives Ior worksite health
promotion programs, improving school lunch programs,
banning junk Ioods in school vending machines, eliminating
tobacco exports, and using increased tobacco taxes Ior initiat-
ing smoking prevention and cessation programs as opposed
to balancing state budgets.
In contrast to the atomistic micro-myopia view of health
education and health promotion as a synonym Ior individual
responsibility, the macro philosophy oI health education and
promotion (O`Rourke, 1989; O`Rourke & Macrina, 1989;
O`Rourke, 2005) encompasses collective responsibility and
community involvement through participation in the political
process andservice on county health boards, city councils,
and school boards. In these capacities, health educators can
infuence the health oI entire communities and not rely on the
'one person at a time model oI improving health through

THE HEALTH EDUCATION MONOGRAPH SERIES, Volume 23, Number 1, 2006
ing bans inpublic places can be enacted, school lunch pro-
grams can be improved, tobacco vending machines can be
eliminated, and bans on tobacco sales to minors can be en-
Iorced. At the macro level, fuoridation oI water supply can be
implemented to substitute the Iar more expensive individual
fuoride treatment by a dentist or the use oI fuoride-added
toothpaste. At the macro level, community recreation op-
portunities can be enhanced and coordinated school health
curricula can be implemented.
The term 'leverage is sometimes used to indicate how
goals can be achieved by using collective power. The same
concept is true in promoting healthy people and healthy com-
munities through collective rather than individual eIIort. It
is generally accepted that the whole is greater than the sum
oI its parts and that teams can achieve better results than
their members acting individually. Yet, health promotion has
been guided more by an emphasis on individual rather than
collective action, with the macro approach playing a distant
second fddle to micro approaches.
The Functional/Utilitarian Philosophy
Let me suggest two other philosophical approaches that
may be useIul Ior health education. The frst is the Iunctional
or utilitarian philosophical perspective (O`Rourke, 2005).
Here the Iocus oI health education/health promotion is not
on individual behavior or liIestyle modifcation. Rather,
the purpose is to improve the health of the citizenry for the
purposes oI promoting a healthy workIorce or a healthier
school-aged population to enhance learning and then as
productive members oI the workIorce, community and
society. This philosophy views health education/promotion
as a means to an end (a healthier, more productive society)
and not the end in terms oI healthier people. For example,
with respect to school health:
Coordinated school health is an essential contributor to
the three R`s. Coordinated school health is an important
element in promoting critical thinking, analysis, deci-
sion- making, and problem solving. Coordinated
school health is an important element for our
youth oI today securing employment Ior tomor-
row (O`Rourke, 2005, p. 113).
In generating community support Ior a school health
cen- ter,
We didn`t achieve this by Iocusing upon primarily on
hav- ing health children. Rather, we Iocused on
the immediate benefts oI having healthier chil-
dren, such as reduced ab- senteeism, reduced dis-
cipline problems, enhanced ability to learn, higher
test scores, Iewer students leIt behind, higher
graduation rates, and so Iorth. (O`Rourke, 2005, p.
The Egalitarian Philosophy
Another more conceptual philosophy advanced by Ber-
zuchka (2001) is the notion oI improving health through an
egalitarian perspective in lieu oI individual liIestyle modifca-
tion. Berzuchka, a medical doctor, contends that, 'Research
during this last decade has shown the health oI a group oI
people is not aIIected substantially by individual behaviors
such as smoking, diet and exercise, by genetics or by the
use oI health care. In countries where basic goods are read-
ily available, people`s liIe span depends on the hierarchical
structure oI their society; that is, the size oI the gap between
rich and poor (Berzuchka, 2001, p.14) For those on top in
a hierarchical situation Ieelings oI power, domination and
coercion predominate while Ieelings oI resignation, resent-
ment and submission predominate Ior those at the bottom.
In contrast an egalitarian environment is characterized by
Ieelings oI support, Iriendship, cooperation and sociability.
Summary
In conclusion, it might be benefcial to resurrect the Siegrist
philosophy that health education and health promotion are not
exclusively synonymous with liIestyle modifcation or the do-
main oI behavioral theorists, but rather the result oI a decent
standard oI living, a saIe environment, a good education, and
meaningIul employment in a society that values collective
responsibility, promotes solidarity, rejects social Darwinism,
and encourages its citizens to care Ior one another, while
respecting individual contributions. It is doubtIul that our
present health education philosophy, with its emphasis on
improving health through individual behavior and liIestyle
modifcation, is suIfcient. Its Iocus is narrow and prevents us
Irom considering more eIIective and eIfcient approaches in
health education and health promotion. The outcomes oI this
tunnel philosophy are a less caring and healthy society and a
narrow, less eIIective health education agenda. A change in
philosophy is essential to maximize opportunities for a more
healthIul society on individual and community levels.
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