Both Ewles and Simnett (2003) and Naidoo and Wills (2000) suggest that there are five key approaches to health-promotion work, each reflecting different objectives and ways of working. Table 7 explores each of these approaches using examples from sexual health.
Broadly speaking the above approaches fall into two main categories - firstly, those that focus on the individual and, arguably, to be successful require clients to modify their behaviour; and secondly, those methods that employ community-centred/societal change approaches.
Many professionals adopt methods that focus on individual approaches with the aims of improving knowledge and awareness of sexual health issues, encouraging the adoption of healthy or safer patterns of behaviour and encouraging those individuals who continue to be at risk to modify and sustain changes in their sexual behaviour. These approaches are attractive to professionals, as they are seen as achievable within busy work schedules, and certainly do have some advantages, as information can be tailored specifically to individual need.
However, professionals need to be aware of the limitations of these approaches, and in particular the need to guard against 'victim blaming'. The majority of sexual health 'problems', such as sexually transmitted infections or unintended pregnancy, are indeed preventable. However, while this may be true, it is simplistic to go on to assume that individuals are at fault and to blame when things go wrong. This discussion will be expanded further below, when we come to examine the challenges to successful sexual health promotion.
A further limitation of approaches focusing on the individual is the tendency to concentrate on 'medical' models of health promotion such as sexual health screening or preventive treatment. Imrie et al. (2005) argue for a more positive approach to health promotion for men who have sex with men than purely concentrating on clinic-based sexual health interventions such as sexual health screening and the treatment of sexually transmitted disease. They point to the fact that many men who have sex with men and who have HIV have a higher prevalence of concurrent psychosocial health problems, including recreational drug use and early childhood sexual abuse, and argue that little has been done to develop and evaluate interventions that address wider behavioural and lifestyle issues.
Mussen et al. (1998) suggest that approaches that address broader influences on sexual health may be more fruitful, in that it may be easier to change some of the factors influencing behaviour than to change sexual health behaviour directly. They suggest that health promoters could concentrate on other
Health promotion strategy
Encourage individuals to take responsibility for their own health and choose healthier lifestyles, e.g. safer sex; using contraception to plan a family.
To give individuals knowledge, and understanding to enable them to make informed decisions about their health e.g. clients will have an understanding about the effects of unsafe sex on their health and will be able to make an informed decision about whether or not to practise safer sex.
To work with clients or communities to meet their perceived needs, e.g. working with client asking for help to practise safer sex or woman wanting to space her family.
To address inequalities in health based on class, race, gender, sexual orientation, geography. Make healthier choices easier choices.
Expert-led, top-down - passive conforming client.
Expert-led, i.e. healthy lifestyle defined by health promoter.
Individual right of free choice. Role of health promoter is to identify educational content.
Client-centred -clients treated as equals. Health promoter is a facilitator. Client becomes empowered.
Need to make environment health-enhancing. Entails social regulation top-down approach, e.g. public health legislation, fiscal controls.
Early detection and treatment of cervical cancer through cervical screening/ Chlamydia screening.
Persuasion through one-to-one advice, leaflets, school sexual health education.
Giving of information about effects of unsafe sex and not using contraception. Helping clients explore their own values and attitudes and come to a decision, e.g. through one-to-one discussion or small groups. Helping clients to change sexual behaviour if they want to, through acquisition of assertiveness skills.
Client to identify health-promotion issue. Use of negotiation, networking facilitation, e.g. 'buddy' system to support clients to practise safer sex or select most appropriate form of contraception for them.
Political and social action to change physical and social environment, e.g. clinics and other sexual health services more available for hard-to-reach groups; encouraging greater acceptance of age, gender and ethnic diversity.
Source: Adapted from Ewles and Simnett 2003.
factors, including recognising the influence of peer norms; empowering communities in their prevention efforts; campaigning for better education in schools; or providing access to appropriate information and services, such as the provision of condoms for anal sex.
Alternative approaches, such as sexual health promotion informed by psy-chosexual counselling models while still focusing on the individual, offer a more positive approach, though they do require more time from the professional. In these approaches the health professional works with the clients to explore the contexts of their lives and relationships and supports them in developing their own personal strategies for sexual health. Abraham and Sheeran (1993) suggest that much sexual activity is not open to negotiation, and therefore sexual skills training, such as training in assertiveness skills, would bring about more effective and empowering change.
Another alternative is to explore community-centred approaches, and there have been good examples in the sexual health promotion field (Watney, 1990; Rhodes, 1990). Rooney and Scott (1992) are very supportive of community action, pointing to the widespread adoption of safer sex and the existence of a supportive and affirmative gay culture providing grassroots community education, and contrast this with the lack of success of individualistic modules of behaviour change. However, Elford et al. (2002) argue that while peer education programmes have been shown to be effective in the United States, they failed to show any significant impact on the risk behaviours of homosexual men in two studies in London and Glasgow.
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