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The WHO health promotion glossary

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HEALTH PROMOTION INTERNATIONAL Vol. 13, No. 4
# Oxford University Press 1998 Printed in Great Britain

Health promotion glossary1

DON NUTBEAM
WHO Collaborating Centre for Health Promotion, Department of Public Health and Community
Medicine, University of Sydney, Sydney, Australia

FOREW O RD: M OVING TOW AR DS A N EW PUBL IC HEAL TH

The first edition of this health promotion glos- developing countries. This was taken a step
sary of terms was published by the World Health further at the 4th International Conference on
Organization (WHO) in 1986 as a guide to Health PromotionÐNew Players for a New Era:
readers of WHO documents and publications. It Leading Health Promotion into the 21st Century,
met a useful purpose in clarifying the meaning which was held in Jakarta, Indonesia in July 1997.
and relationship between the many terms which Several WHO programmes and projects have
were not in common usage at that time. This first been developed and implemented which have
edition of the glossary has been translated into sought to translate health promotion concepts
several languages (French, Spanish, Russian, and strategies into practical action. These in-
Japanese and Italian), and the terms defined clude: the `Healthy Cities, Villages, Municipali-
have been widely used both within and outside ties' and `Healthy Islands' projects; the networks
WHO. The glossary was adapted and republished of `Health Promoting Schools' and `Health Pro-
in German in 1990. moting Hospitals'; the `Healthy Marketplaces
Much has happened since the publication of and `Health Promoting Workplaces' projects; as
the glossary a decade ago. Most notably, in well as WHO action plans on alcohol and
October 1986 the First International Conference tobacco, active living and healthy ageing.
on Health Promotion was held in Ottawa, Recent developments in health systems around
Canada, producing what is now widely known the world have given new prominence to health
as the Ottawa Charter for Health Promotion. This promotion approaches. The increasing focus on
conference was followed by others which health outcomes reconfirms the priority placed
explored the major themes of the Ottawa Charter on investment in the determinants of health
on healthy public policy (in Adelaide, 1988), and through health promotion. Continually asking
on supportive environments for health (in Sunds- the question `where is health created?' links
vall, 1991). These conferences have added greatly health promotion to two major reform debates:
to our understanding of health promotion strat- the formulation of new public health strategies,
egies and their practical application, as well as and the need to re-orient health services. The
more fully accounting for issues of relevance to foresight shown in the Ottawa Charter has been
adopted by many countries and organizations
1
This paper was originally prepared as a resource docu- around the worldÐa process which was taken
ment for the 4th International Conference on Health Promo- one step further through the 4th International
tionÐNew Players for a New Era: Leading Health Promotion Conference on Health Promotion in Jakarta, July
into the 21st Century, Jakarta, Indonesia, 21±25 July 1997. It
was subsequently revised to account for the outcomes from 1997. This Conference adopted the Jakarta
that conference, specifically the Jakarta Declaration on Lead- Declaration on Leading Health Promotion into
ing Health Promotion into the 21st Century. the 21st Century. A number of terms that are
349
350 D. Nutbeam

central to the Jakarta Declaration have therefore as possible to understand the basic ideas and
been included in this new version of the health concepts which are central to the development
promotion glossary. of health promotion strategies and practical
Ilona Kickbusch action. By clarifying the key terminology, this
Chair, Editorial Board glossary is a part of the deliberate approach to
engage as wide a constituency as possible in
actions to promote health and prevent disease.
IN TR O DU CT IO N

With a decade of experience, and continued evo- N O TES

lution and development of ideas since the pro-
duction of the first glossary, this revision provides The glossary consists of two sections. The first
an updated overview of the many ideas and con- contains seven core definitions which are central
cepts which are central to contemporary health to the concept and principles of health promo-
promotion. This time, as previously, the basic aim tion, and are discussed in greater detail. This is
of the glossary is to facilitate communication both followed by the main section which includes an
between countries and within countries, and extended list of 50 terms which are commonly
among the various agencies and individuals work- used in health promotion. The list is presented in
ing in the field. As before, the definitions should alphabetical order.
not be regarded as `the final word' on the terms Whenever possible, definitions have been taken
included. As experience grows and ideas evolve or adapted from WHO publicationsÐparticu-
further the terms will need to be regularly assessed larly in the case of core definitions. Most defini-
for their meaning and relevance. tions are followed by a note of further
This version of the glossary is substantially explanation or qualification. When appropriate,
different from the original. Some terms have the source of different terms in the main section
been omitted, many have been modified in the of the glossary has been given in the text. Some of
light of experiences and evolution in concepts, the definitions are original to the glossary, or are
and new terms which are in current use have been composites of definitions which reflect different
included. The list of terms included is not perspectives to the term cited. The Bibliography
intended to be either exhaustive or exclusive, lists all the WHO sources referred to directly in
and draws upon the wide range of disciplines the text. Earlier drafts of this revision to the
from which health promotion has its origins. In glossary were circulated to all Regional Offices
a number of cases the definition adopted reflects of WHO for comment and consultation. Feed-
the application of the term in the context of back from this process has resulted in important
health promotion. This focus is acknowledged changes to several definitions in the glossary.
in the definition. Many of the definitions are derived from the
As in the original version, the definitions have first version of the glossary published in 1986.
been kept short, and make no pretence to offer Some remain identical to the early version
fuller interpretations which may be found else- [referred to by `Health Promotion Glossary
where in other publications. Where relevant, (1986)'], but many have been modified to account
some notes of explanation have been added. for changes in use and evolution in concepts
Similarly, the use of terms will often be situ- (referred to as `modified definition').
ation-specific, and moulded by prevailing social, Some terms within the definitions and notes
cultural and economic conditions. It will be are highlighted in bold to assist the reader in
apparent that some of the concepts and defini- cross-referencing with other definitions. This
tions that have been adopted in the glossary cross referencing is intended to improve under-
reflect the language and cultural bias of the standing of the inter-relationships between dif-
principal author. Definitions by their very ferent terms and concepts.
nature are restrictive, representing summaries of
complex ideas and actions. Such restrictions are
fully acknowledged in the drafting of the defini-
tions used in this glossary.
Despite these obvious restrictions, the glossary
has been assembled to enable as wide an audience
 Health promotion glossary 351
HE ALT H PRO MO T IO N G LO SS AR Y economic conditions so as to alleviate their
impact on public and individual health. Health
Basic terms promotion is the process of enabling people to
Health increase control over the determinants of health
and thereby improve their health. Participation is
Health is defined in the WHO constitution of
essential to sustain health promotion action.
1948 as:
The Ottawa Charter identifies three basic strat-
A state of complete physical, social and mental well- egies for health promotion. These are: advocacy
being, and not merely the absence of disease or for health to create the essential conditions for
infirmity. health indicated above; enabling all people to
achieve their full health potential; and mediating
Health is regarded by WHO as a fundamental
between the different interests in society in the
human right and, correspondingly, all people
pursuit of health.
should have access to basic resources for health.
These strategies are supported by five priority
Within the context of health promotion, health
action areas which are the basic tools for health
has been considered less as an abstract state and
promotion. In the Ottawa Charter health promo-
more as a means to an end which can be
tion action means:
expressed in functional terms as a resource
which permits people to lead an individually, . build healthy public policy;
socially and economically productive life: . create supportive environments for health;
. strengthen community action for health;
Health is a resource for everyday life, not the object of
living. It is a positive concept emphasizing social and . develop personal skills;
personal resources as well as physical capabilities. . re-orient health services.
Reference: WHO (1986) Ottawa Charter. Each of these strategies and action areas is
In keeping with the concept of health as a further defined in the glossary.
fundamental human right, the Ottawa Charter The Jakarta Declaration on Leading Health
emphasizes certain prerequisites for health which Promotion into the 21st Century from July 1997
include peace, adequate economic resources, confirmed that these strategies and action areas
food and shelter, and a stable ecosystem and are relevant for all countries. Furthermore, there
sustainable resource use. Recognition of these is clear evidence that:
prerequisites highlights the inextricable links . Comprehensive approaches to health develop-
between social and economic conditions, the ment are the most effective. Those that use
physical environment, individual lifestyles and combinations of the five strategies are more
health. These links provide the key to an holistic effective than single-track approaches.
understanding of health which is central to the . Settings for health offer practical opportunities
definition of health promotion. for the implementation of comprehensive strat-
A comprehensive understanding of health egies.
implies that all systems and structures which . Participation is essential to sustain efforts.
govern social and economic conditions and the People have to be at the centre of health
physical environment should take account of the promotion action and decision-making pro-
implications of their activities in relation to their cesses for them to be effective.
impact on individual and collective health and . Health literacy fosters participation. Access to
well-being. education and information is essential to
achieving effective participation and the
Health promotion
empowerment of people and communities.
Health promotion is the process of enabling people to
increase control over, and to improve their health. For health promotion into the 21st century the
Jakarta Declaration identifies five priorities:
Reference: WHO (1986) Ottawa Charter.
Health promotion represents a comprehensive . promote social responsibility for health;
social and political process; it not only embraces . increase investments for health development;
actions directed at strengthening the skills and . expand partnerships for health promotion;
capabilities of individuals, but also action direc- . increase community capacity and empower the
ted towards changing social, environmental and individual;
352 D. Nutbeam
. secure an infrastructure for health promotion. between the `old' and the `new' may not be so
necessary in the future as the mainstream concept
Each of these priorities is further defined in the
of public health develops and expands.
glossary. Increasing community capacity is ad-
The concept of `ecological public health' has
dressed in the definition of community action for
also emerged in the literature. It has evolved in
health. Empowerment for health is included as a
response to the changing nature of health issues
definition.
and their interface with emerging global environ-
Health for All mental problems. These new problems include
The attainment by all the people of the world of a level
global ecological risks such as the destruction of
of health that will permit them to lead a socially and the ozone layer, uncontrolled and unmanageable
economically productive life. air and water pollution, and global warming.
These developments have a substantial impact
Reference: WHO (1984) Glossary of Terms used on health which often elude simple models of
in the `Health for All' Series. causality and intervention.
Health for All has served as an important focal Ecological public health emphasizes the
point for health strategy for WHO and most common ground between achieving health and
member states for almost 20 years. Although it sustainable development. It focuses on the eco-
has been interpreted differently by each country nomic and environmental determinants of health,
in the light of its social and economic character- and on the means by which economic investment
istics, the health status and morbidity patterns of should be guided towards producing the best
its population, and the state of development of its population health outcomes, greater equity in
health system, it has provided an aspirational health, and sustainable use of resources.
goal, based on the concept of equity in health.
The Health for All strategy is currently being re- Primary health care
developed to ensure its continued relevance into
the next century. A new policy is being devel- Primary health care is essential health care made
oped, to be adopted by the World Health Assem- accessible at a cost a country and community can
afford, with methods that are practical, scientifically
bly in 1998.
sound and socially acceptable.
Public health Reference: WHO (1978) Alma Ata Declaration.
The science and art of promoting health, preventing The Alma Ata Declaration also emphasizes
disease, and prolonging life through the organized
that everyone should have access to primary
efforts of society.
health care, and everyone should be involved in
Reference: new definition. it. The primary health care approach encom-
Public health is a social and political concept passes the following key components: equity,
aimed at improving health, prolonging life and community involvement/participation, intersec-
improving the quality of life among whole popu- torality, appropriateness of technology and
lations through health promotion, disease pre- affordable costs.
vention and other forms of health intervention. A As a set of activities, primary health care
distinction has been made in the health promo- should include, at the very least, health education
tion literature between public health and a new for individuals and the whole community on the
public health for the purposes of emphasizing size and nature of health problems, and on
significantly different approaches to the descrip- methods of preventing and controlling these
tion and analysis of the determinants of health, problems. Other essential activities include: the
and the methods of solving public health prob- promotion of adequate supplies of food and
lems. This new public health is distinguished by its proper nutrition; sufficient safe water and basic
basis in a comprehensive understanding of the sanitation; maternal and child health care, in-
ways in which lifestyles and living conditions cluding family planning; immunization; appro-
determine health status, and a recognition of priate treatment of common diseases and injuries;
the need to mobilize resources and make sound and the provision of essential drugs.
investments in policies, programmes and services Primary health care as defined above will do
which create, maintain and protect health by much to address many of the prerequisites for
supporting healthy lifestyles and creating sup- health indicated earlier. In addition, at a very
portive environments for health. Such a distinction practical level, there is great scope for both
 Health promotion glossary 353

planned and opportunistic health promotion impacting on health, as well as individual risk
through the day to day contact between primary factors and risk behaviours, and use of the health
health care personnel and individuals in their care system. Thus, health education may involve
community. Through health education with the communication of information, and develop-
clients and advocacy on behalf of their commun- ment of skills which demonstrate the political
ity, primary health care personnel are well placed feasibility and organizational possibilities of vari-
both to support individual needs and to influence ous forms of action to address social, economic
the policies and programmes that affect the and environmental determinants of health.
health of the community. In the past, health education was used as a
The primary health care concept and themes term to encompass a wider range of actions
are currently being reviewed by WHO. including social mobilization and advocacy.
These methods are now encompassed in the
Disease prevention term health promotion, and a narrower definition
Disease prevention covers measures not only to pre- of health education is proposed here to emphas-
vent the occurrence of disease, such as risk factor ize the distinction.
reduction, but also to arrest its progress and reduce
its consequences once established.
Main glossary
Reference: adapted from WHO (1984) HFA Glos- Advocacy for health
sary of Terms. A combination of individual and social actions
Primary prevention is directed towards pre- designed to gain political commitment, policy support,
venting the initial occurrence of a disorder. social acceptance and systems support for a particular
Secondary and tertiary prevention seeks to health goal or programme.
arrest or retard existing disease and its effects
Reference: WHO (1992) Advocacy Strategies for
through early detection and appropriate treat-
Health and Development.
ment; or to reduce the occurrence of relapses and
Such action may be taken by and/or on behalf
the establishment of chronic conditions through,
of individuals and groups to create living condi-
for example, effective rehabilitation.
tions which are conducive to health and the
Disease prevention is sometimes used as a
achievement of healthy lifestyles. Advocacy is
complementary term alongside health promo-
one of the three major strategies for health pro-
tion. Although there is frequent overlap between
motion and can take many forms including the
the content and strategies, disease prevention is
use of the mass media and multi-media, direct
defined separately. Disease prevention in this
political lobbying, and community mobilization
context is considered to be action which usually
through, for example, coalitions of interest
emanates from the health sector, dealing with
around defined issues. Health professionals
individuals and populations identified as exhibit-
have a major responsibility to act as advocates
ing identifiable risk factors, often associated with
for health at all levels in society.
different risk behaviours.
Alliance
Health education An alliance for health promotion is a partnership
Health education comprises consciously constructed between two or more parties that pursue a set of
opportunities for learning involving some form of agreed upon goals in health promotion.
communication designed to improve health literacy,
including improving knowledge, and developing life Reference: new definition.
skills which are conducive to individual and commun- Alliance building will often involve some form
ity health. of mediation between the different partners in the
definition of goals and ethical ground rules, joint
Reference: modified definition. action areas, and agreement on the form of
Health education is not only concerned with cooperation which is reflected in the alliance.
the communication of information, but also with
fostering the motivation, skills and confidence Community
(self-efficacy) necessary to take action to improve A specific group of people, often living in a defined
health. Health education includes the commun- geographical area, who share a common culture, values
ication of information concerning the underlying and norms, are arranged in a social structure according
social, economic and environmental conditions to relationships which the community has developed
354 D. Nutbeam
over a period of time. Members of a community gain outside of the control of individuals and groups.
their personal and social identity by sharing common These include, for example, income and social
beliefs, values and norms which have been developed status, education, employment and working con-
by the community in the past and may be modified in ditions, access to appropriate health services, and
the future. They exhibit some awareness of their iden-
the physical environments which, in combina-
tity as a group, and share common needs and a
commitment to meeting them. tion, create different living conditions which
impact on health. Achieving change to these life-
Reference: modified definition. styles and living conditions which determine
In many societies, particularly those in devel- health status are considered to be intermediate
oped countries, individuals do not belong to a health outcomes.
single, distinct community, but rather maintain
membership of a range of communities based on Empowerment for health
variables such as geography, occupation, social In health promotion, empowerment is a process
and leisure interests. through which people gain greater control over deci-
sions and actions affecting their health.
Community action for health
Community action for health refers to collective efforts Reference: new definition.
by communities which are directed towards increasing Empowerment may be a social, cultural,
community control over the determinants of health, and psychological or political process through which
thereby improving health. individuals and social groups are able to express
their needs, present their concerns, devise strat-
Reference: new definition. egies for involvement in decision-making, and
The Ottawa Charter emphasizes the import- achieve political, social and cultural action to
ance of concrete and effective community action meet those needs. Through such a process
in setting priorities for health, making decisions, people see a closer correspondence between
planning strategies and implementing them to their goals in life and a sense of how to achieve
achieve better health. The concept of community them, and a relationship between their efforts and
empowerment is closely related to the Ottawa life outcomes. Health promotion not only encom-
Charter definition of community action for passes actions directed at strengthening the basic
health. In this concept an empowered community life skills and capacities of individuals, but also at
is one in which individuals and organizations influencing underlying social and economic con-
apply their skills and resources in collective ditions and physical environments which impact
efforts to address health priorities and meet upon health. In this sense health promotion is
their respective health needs. Through such par- directed at creating the conditions which offer a
ticipation, individuals and organizations within better chance of there being a relationship
an empowered community provide social support between the efforts of individuals and groups,
for health, address conflicts within the commun- and subsequent health outcomes in the way
ity, and gain increased influence and control over described above.
the determinants of health in their community. A distinction is made between individual and
`community empowerment', where individual
Determinants of health
empowerment refers primarily to the individual's
The range of personal, social, economic and environ- ability to make decisions and have control over
mental factors which determine the health status of
his or her personal life in health promotion.
individuals or populations.
Community empowerment involves individuals
Reference: new definition. acting collectively to gain greater influence and
The factors which influence health are multiple control over the determinants of health and the
and interactive. Some determinants of health are quality of life in their community, and is an
not modifiable (for example age, sex and genetic important goal in community action for health.
endowment). Health promotion is fundamentally
concerned with action to address the full range of Enabling
potentially modifiable determinants of healthÐ In health promotion, enabling means taking action in
not only those which are related to the actions of partnership with individuals or groups to empower
individuals, such as health behaviours and life- them, through the mobilization of human and material
styles, but also those factors which are largely resources, to promote and protect their health.
 Health promotion glossary 355

Reference: new definition. and just access to resources for health. Equity in
The emphasis in this definition on empower- health is not the same as equality in health status.
ment through partnership, and on the mobiliza- Inequalities in health status between individuals
tion of resources draws attention to the and populations are inevitable consequences of
important role of health workers and other genetic differences, of different social and eco-
health activists acting as a catalyst for health nomic conditions, or a result of personal lifestyle
promotion action, for example by providing choices. Inequities occur as a consequence of
access to information on health, by facilitating differences in opportunity which result, for ex-
skills development, and by supporting access to ample, in unequal access to health services, to
the political processes which shape public policies nutritious food, adequate housing and so on. In
affecting health. such cases, inequalities in health status arise as a
consequence of inequities in opportunities in life.
Epidemiology
Epidemiology is the study of the distribution and Health behaviour
determinants of health-states or events in specified Any activity undertaken by an individual, regardless of
populations, and the application of this study to the actual or perceived health status, for the purpose of
control of health problems. promoting, protecting or maintaining health, whether
or not such behaviour is objectively effective towards
Reference: Last, J. M. (1988) Dictionary of Epi- that end.
demiology. Oxford University Press, Oxford.
Epidemiological information, particularly that Reference: Health Promotion Glossary (1986).
defining individual, population and/or physical It is possible to argue that almost every beha-
environmental risks has been at the core of public viour or activity by an individual has an impact
health, and provided the basis for disease preven- on health status. In this context it is useful to
tion activities. Epidemiological studies use social distinguish between behaviours which are pur-
classifications (such as socioeconomic status) in posefully adopted to promote or protect health
the study of disease in populations, but generally (as in the definition above), and those which may
make less than optimal use of social sciences, be adopted regardless of consequences to health.
including economic and public policy informa- Health behaviours are distinguished from risk
tion, in investigating and understanding disease behaviours which are defined separately as beha-
and health in populations. viours associated with increased susceptibility to
`Social epidemiology' has evolved as a discip- a specific cause of ill-health.
line during the past two decades. Social epide- Health behaviours and risk behaviours are
miology is the study of health and illness in often related in clusters in a more complex pat-
populations which is informed by social, psycho- tern of behaviours referred to as lifestyles.
logical, economic and public policy information, Health communication
and uses that information in the definition of
Interpersonal or mass communication activities which
public health problems and proposal of solutions. are directed towards improving the health status of
As the discipline of epidemiology further devel- individuals and populations. Health communication
ops and expands, such distinctions will be less may involve the integration of mass and multi-media
important in the future. communication with more local and/or personal tradi-
tional forms of communication.
Equity in health
Reference: new definition.
Equity means fairness. Equity in health means that
In the past, health communication has been
people's needs guide the distribution of opportunities
for well-being employed to achieve community support for or
compliance with pre-determined objectives.
Reference: WHO (1995) Equity in Health and However, advances in communication media
Health Care. continue to improve access to health information.
The WHO global strategy of achieving Health In this respect, health communication becomes
for All is fundamentally directed towards achiev- an increasingly important element to achieving
ing greater equity in health between and within greater empowerment of individuals and com-
populations, and between countries. This implies munities. Health communication is not only
that all people have an equal opportunity to directed to the people from government, but
develop and maintain their health, through fair can come from the people as a form of advocacy
356 D. Nutbeam

for health directed towards the achievement of health creation, maintenance and protection, em-
healthy public policies, or the creation of support- phasizing a healthy life span.
ive environments for health.
Health communication can take many forms, Health gain
ranging from the use of modern multi-media Health gain is a way to express improved health out-
communications through to traditional and comes. It can be used to reflect the relative advantage
culture-specific forms of communication such as of one form of health intervention over another in
story-telling, puppet shows and songs. Health producing the greatest health gain.
communication may take the form of discreet Reference: new definition.
health messages, or be incorporated into existing The Jakarta Declaration indicates that health
communication media, including news media, promotion `acts on the determinants of health to
advertising and sponsorship, and popular enter- create the greatest health gain for people'. (See
tainment. In the last case this form of health also health outcome, intermediate health out-
communication is often referred to as `edutain- comes.)
ment'.
Health goal
Health development Health goals summarize the health outcomes which, in
Health development is the process of continuous, the light of existing knowledge and resources, a coun-
progressive improvement of the health status of indi- try or community might hope to achieve in a defined
viduals and groups in a population. time period.

Reference: WHO Terminology Information Reference: new definition.

System (1997). Health goals are general statements of intent
The Jakarta Declaration describes health pro- and aspiration, intended to reflect the values of
motion as an essential element of health develop- the community in general, and the health sector
ment. in particular, regarding a healthy society. Many
countries have adopted an approach to setting
health goals and health targets as statements of
Health expectancy
direction and intent with regard to their invest-
Health expectancy is a population based measure of ments for health. WHO has supported the devel-
the proportion of expected life span estimated to be opment, and promoted the use of health goals
healthful and fulfilling, or free of illness, disease and and targets at both global and regional levels
disability according to social norms and perceptions
and professional standards. Health indicator
Reference: new definition. A health indicator is a characteristic of an individual,
Health expectancy belongs to a new generation population, or environment which is subject to meas-
or type of health indicators which are currently urement (directly or indirectly) and can be used to
describe one or more aspects of the health of an
being developed. These indicators are intended to individual or population (quality, quantity and time).
create measures which are more sensitive to the
determinants and dynamics of health. Health Reference: modified definition.
expectancy indicators combine information Health indicators can be used to define public
from life expectancy tables and health surveys health problems at a particular point in time, to
of populations. They need to be based on life indicate change over time in the level of the
expectancy at country level or a similar geo- health of a population or individual, to define
graphic area. differences in the health of populations, and to
Examples of health expectancy indicators cur- assess the extent to which the objectives of a
rently in use are disability free life years (DFLY) programme are being reached.
and quality adjusted life years (QALY). They Health indicators may include measurements
focus primarily on the extent to which individuals of illness or disease which are more commonly
experience a life span free of disability, disorders used to measure health outcomes, or positive
and/or chronic disease. Health promotion seeks aspects of health (such as quality of life, life
to expand the understanding of health expec- skills, or health expectancy), and of behaviours
tancy beyond the absence of disease, disorder and actions by individuals which are related to
and disability towards positive measures of health. They may also include indicators which
 Health promotion glossary 357

measure the social and economic conditions and parameters for action in response to health needs,
the physical environment as it relates to health, available resources and other political pressures.
measures of health literacy and healthy public
Reference: modified definition.
policy. This latter group of indicators may be
Health policy is often enacted through legisla-
used to measure intermediate health outcomes and
tion or other forms of rule-making which define
health promotion outcomes.
regulations and incentives that enable the provi-
Health literacy sion of health services and programmes, and
access to those services and programmes.
Health literacy represents the cognitive and social skills
which determine the motivation and ability of indi- Health policy is currently distinguished from
viduals to gain access to, understand and use informa- healthy public policy by its primary concern with
tion in ways which promote and maintain good health. health services and programmes. Future progress
in health policies may be observed through the
Reference: new definition. extent to which they may also be defined as
Health literacy implies the achievement of a healthy public policies.
level of knowledge, personal skills and confidence As with most policies, health policies arise
to take action to improve personal and commun- from a systematic process of building support
ity health by changing personal lifestyles and for public health action that draws upon avail-
living conditions. Thus, health literacy means able evidence, integrated with community prefer-
more than being able to read pamphlets and ences, political realities and resource availability.
make appointments. By improving people's
access to health information, and their capacity Health Promoting Hospitals
to use it effectively, health literacy is critical to A health promoting hospital does not only provide
empowerment. Health literacy is itself dependent high quality comprehensive medical and nursing ser-
upon more general levels of literacy. Poor literacy vices, but also develops a corporate identity that
can affect people's health directly by limiting embraces the aims of health promotion, develops a
their personal, social and cultural development, health promoting organizational structure and culture,
as well as hindering the development of health including active, participatory roles for patients and all
literacy. members of staff, develops itself into a health promot-
ing physical environment and actively cooperates with
Health outcomes its community.
A change in the health status of an individual, group or Reference: adapted from WHO (1991) Budapest
population which is attributable to a planned interven-
tion or series of interventions, regardless of whether Declaration on Health Promoting Hospitals.
such an intervention was intended to change health Health promoting hospitals take action to
status. promote the health of their patients, their staff,
and the population in the community they are
Reference: new definition. located in. Health promoting hospitals are
Such a definition emphasizes the outcome of actively attempting to become `healthy organ-
planned interventions (as opposed, for example, izations'. The Health Promoting Hospital is a
to incidental exposure to risk), and that outcomes concept in development since 1988. An inter-
may be for individuals, groups or whole popula- national network has developed to promote the
tions. Interventions may include government pol- wider adoption of this concept in hospitals and
icies and consequent programmes, laws and other health care settings.
regulations, or health services and programmes,
including health promotion programmes. They Health Promoting Schools
may also include the intended or unintended A health promoting school can be characterized as a
health outcomes of government policies in sectors school constantly strengthening its capacity as a
other than health. Health outcomes will normally healthy setting for living, learning and working.
be assessed using health indicators. (See also
intermediate health outcomes, and health promo- Reference: WHO (1997) Promoting Health
tion outcomes.) through Schools: Report of a WHO Expert Com-
mittee on Comprehensive School Health Education
Health policy and Promotion. WHO Technical Report Series.
A formal statement or procedure within institutions Towards this goal, a health promoting school
(notably government) which defines priorities and the engages health and education officials, teachers,
358 D. Nutbeam

students, parents and community leaders in comes is directed towards enabling individuals
efforts to promote health. It fosters health and or communities to exert control over the deter-
learning with all the measures at its disposal, and minants of health which are defined as intermedi-
strives to provide supportive environments for ate health outcomes.
health and a range of key school health education In many cases it is difficult to trace the path-
and promotion programs and services. A health way which links health promotion activities to
promoting school: implements policies, practices health outcomes. This may be because of the long
and other measures that respect an individual's time-lag between action and outcome, and
self esteem; provides multiple opportunities for because of the technical difficulties of isolating
success; and acknowledges good efforts and cause and effect in complex, `real-life' situations.
intentions as well as personal achievements. It In most cases, there is also `value' placed on the
strives to improve the health of school personnel, process by which different outcomes are
families and community members as well as achieved. In terms of valued processes, evalua-
students, and works with community leaders to tions of health promotion activities may be `par-
help them understand how the community con- ticipatory', involving all those with a vested
tributes to health and education. interest in the initiative; `pluralistic', involving a
WHO's Global School Health Initiative aims variety of disciplinary perspectives; may help
at helping all schools to become `health promot- build the capacities of individuals, communities,
ing' schools by, for example, encouraging and organizations and governments to address im-
supporting international, national and subna- portant health problems, and may be `integrated'
tional networks of Health Promoting Schools, into all stages of the development and implemen-
and helping to build national capacities to pro- tation of a health promotion initiative.
mote health through schools.
Health sector
Health promotion outcomes The health sector consists of organized public and
Health promotion outcomes are changes to personal private health services (including health promotion,
characteristics and skills, and/or social norms and disease prevention, diagnostic, treatment and care
actions, and/or organizational practices and public services), the policies and activities of health depart-
policies which are attributable to a health promotion ments and ministries, health related non-government
activity. organizations and community groups, and professional
associations.
Reference: new definition.
Reference: adapted from WHO (1984) HFA Glos-
Health promotion outcomes represent the
sary of Terms.
most immediate results of health promotion
activities and are generally directed towards Health status
changing modifiable determinants of health. A description and/or measurement of the health of an
Health promotion outcomes include health lit- individual or population at a particular point in time
eracy, healthy public policy, and community action against identifiable standards, usually by reference to
for health. (See also health outcomes and inter- health indicators.
mediate health outcomes.)
Reference: adapted from WHO (1984) HFA Glos-
Health promotion evaluation sary of Terms.
Health promotion evaluation is an assessment of the Health target
extent to which a health promotion action achieves a
Health targets state, for a given population, the
`valued' outcome.
amount of change (using a health indicator) which
Reference: new definition. could reasonably be expected within a defined time
To this end, assessment of the extent to which period. Targets are generally based on specific and
measurable changes in health outcomes, or intermediate
health promotion actions enable individuals or
health outcomes.
communities to exert control over the determi-
nants of health represents a central element to Reference: new definition.
evaluation in health promotion. Health promo- Health targets define the concrete steps which
tion outcomes represent the first point of assess- may be taken towards the achievement of health
ment for many health promotion activities. goals. Setting targets also provides one approach
Achievement of these health promotion out- to the assessment of progress in relation to a
 Health promotion glossary 359

defined health policy or programme by defining a for citizens. It makes social and physical environments
benchmark against which progress can be meas- health enhancing.
ured. Setting targets requires the existence of a
Reference: WHO (1988) Adelaide Conference
relevant health indicator and information on the
Recommendations.
distribution of that indicator within a population
The Ottawa Charter highlighted the fact that
of interest. It also requires an estimate of current
health promotion action goes beyond the health
and likely future trends in relation to change in
care sector, emphasizing that health should be on
the distribution of the indicator, and an under-
the policy agenda in all sectors, and at all levels of
standing of the potential to change the distribu-
government. One important element in building
tion of the indicator in the population of interest.
healthy public policy is the notion of account-
Healthy Cities ability for health. Governments are ultimately
accountable to their people for the health con-
A healthy city is one that is continually creating and
sequences of their policies, or lack of policies. A
improving those physical and social environments and
expanding those community resources which enable commitment to healthy public policies means
people to mutually support each other in performing that governments must measure and report on
all the functions of life and in developing to their their investments for health, and the subsequent
maximum potential. health outcomes, and intermediate health out-
comes of their investments and policies in a
Reference: WHO (EURO) (1994) Terminology language that all groups in society readily under-
for the European Health Policy Conference. stand. Closely related to the health promotion
The WHO Healthy Cities project is a long-term concept of healthy public policy is the strategy of
development project that seeks to place health on investment for health. Investment for health is a
the agenda of cities around the world, and to strategy for optimizing the health promoting
build a constituency of support for public health impact of public policies.
at the local level. The Healthy Cities concept is
evolving to encompass other forms of settlement Infrastructure for health promotion
including Healthy Villages and Municipalities. Those human and material resources, organizational
and administrative structures, policies, regulations and
Healthy Islands incentives which facilitate an organized health promo-
A healthy island is one that is committed to and tion response to public health issues and challenges.
involved in a process of achieving better health and
quality of life for its people, and healthier physical and Reference: new definition.
social environments in the context of sustainable devel- Such infrastructures may be found through a
opment. diverse range of organizational structures, includ-
ing primary health care, government, private
Reference: adapted from WHO (WPRO) (1995)
sector and non-government organizations, self-
Yanuca Island Declaration.
help organizations, as well as dedicated health
The Yanuca Island Declaration states that
promotion agencies and foundations. Although
Healthy Islands are places where: children are
many countries have a dedicated health promo-
nurtured in body and mind; environments invite
tion workforce, the greater human resource is to
learning and leisure; people work and age in
be found among the wider health workforce,
dignity; and ecological balance is a source of
workforces in other sectors than health (for ex-
pride. This declaration was ratified by the
ample, in education, social welfare and so on),
Health Ministers of 14 Pacific Island nations in
and from the actions of lay persons within indi-
1995 and has since become an inter-regional
vidual communities. Infrastructure for health
source of reference for Healthy Islands pro-
promotion can be found not only in tangible
grammes throughout the world.
resources and structures, but also through the
Healthy public policy extent of public and political awareness of health
issues, and participation in action to address
Healthy public policy is characterized by an explicit
concern for health and equity in all areas of policy, and
those issues.
by an accountability for health impact. The main aim
of healthy public policy is to create a supportive Intermediate health outcomes
environment to enable people to lead healthy lives. Intermediate health outcomes are changes in the deter-
Such a policy makes healthy choices possible or easier minants of health, notably changes in lifestyles, and
360 D. Nutbeam
living conditions which are attributable to a planned ments for health are undertaken by people in the
intervention or interventions, including health promo- context of their everyday life as part of personal
tion, disease prevention and primary health care. and family health maintenance strategies. (See
Reference: new definition. also healthy public policy, supportive environments
See also determinants of health, health outcomes for health.)
and intermediate health outcomes.
Jakarta Declaration on Health Promotion into
Intersectoral collaboration the 21st Century
See Health promotion.
A recognized relationship between part or parts of
different sectors of society which has been formed to
take action on an issue to achieve health outcomes or Life skills
intermediate health outcomes in a way which is more Life skills are abilities for adaptive and positive beha-
effective, efficient or sustainable than might be viour, that enable individuals to deal effectively with
achieved by the health sector acting alone. the demands and challenges of everyday life.

Reference: modified from WHO (1997) Inter- Reference: WHO (1993) Life Skills Education in
sectoral Action for Health: A Cornerstone for Schools.
Health-for-All in the 21st Century. Life skills consist of personal, interpersonal,
Intersectoral action for health is seen as central cognitive and physical skills which enable
to the achievement of greater equity in health, people to control and direct their lives, and to
especially where progress depends upon decisions develop the capacity to live with and produce
and actions in other sectors, such as agriculture, change in their environment. Examples of indi-
education and finance. A major goal in intersec- vidual life skills include decision-making and
toral action is to achieve greater awareness of the problem-solving, creative thinking and critical
health consequences of policy decisions and thinking, self-awareness and empathy, commun-
organizational practice in different sectors and, ication skills and interpersonal relationship
through this, movement in the direction of skills, coping with emotions and managing
healthy public policy and practice. Not all inter- stress. Life skills as described above are funda-
sectoral action for health need involve the health mental building blocks for the development of
sector. For example, in some countries the police personal skills for health promotion described as
and transport sectors might combine to take one of the key action areas in the Ottawa
action to reduce road transport injury. Such Charter.
action, although explicitly intended to reduce
injury, will not always involve the health sector. Lifestyle (lifestyles conducive to health)
Lifestyle is a way of living based on identifiable
Investment for health patterns of behaviour which are determined by the
Investment for health refers to resources which are interplay between an individual's personal character-
explicitly dedicated to the production of health and istics, social interactions, and socioeconomic and en-
health gain. They may be invested by public and private vironmental living conditions.
agencies as well as by people as individuals and groups. Reference: modified definition.
Investment for health strategies are based on know-
These patterns of behaviour are continually
ledge about the determinants of health and seek to gain
political commitment to healthy public policies. interpreted and tested out in different social situ-
ations and are therefore not fixed, but subject to
Reference: new definition. change. Individual lifestyles, characterized by
Investment for health is not restricted to re- identifiable patterns of behaviour, can have a
sources which are devoted to the provision and profound effect on an individual's health and
use of health services and may include, for ex- on the health of others. If health is to be
ample, investments made by people (individually improved by enabling individuals to change
or collectively) in education, housing, empower- their lifestyles, action must be directed not only
ment of women, or child development. Greater at the individual but also at the social and living
investment for health also implies reorientation conditions which interact to produce and main-
of existing resource distribution within the health tain these patterns of behaviour.
sector towards health promotion and disease It is important to recognize, however, that
prevention. A significant proportion of invest- there is no `optimal' lifestyle to be prescribed
 Health promotion glossary 361

for all people. Culture, income, family structure, health promotion in order to build a global
age, physical ability, home and work environ- alliance for health promotion.
ment will make certain ways and conditions of
living more attractive, feasible and appropriate. Ottawa Charter for Health Promotion
See Health promotion.
Living conditions
Living conditions are the everyday environment of Partnership for health promotion
people, where they live, play and work. These living A partnership for health promotion is a voluntary
conditions are a product of social and economic cir- agreement between two or more partners to work
cumstances and the physical environmentÐall of cooperatively towards a set of shared health outcomes
which can impact upon healthÐand are largely outside
of the immediate control of the individual. Reference: new definition.
Such partnerships may form a part of inter-
Reference: modified definition. sectoral collaboration for health, based on alli-
The Ottawa Charter action of creating support- ances for health promotion. Such partnerships
ive environments for health is largely focused on may be limited by the pursuit of a clearly defined
the need to improve and change living conditions goalÐsuch as the successful development and
to support health. introduction of legislationÐor may be on-
going, covering a broad range of issues and
Mediation initiatives.
In health promotion, a process through which the
different interests (personal, social, economic) of indi- Personal skills
viduals and communities, and different sectors (public
and private) are reconciled in ways that promote and
See Life skills.
protect health.
Quality of life
Reference: new definition. The perception of individuals that their needs are being
Producing change in people's lifestyles and satisfied and that they are not being denied opportun-
living conditions inevitably produces conflicts ities to achieve happiness and fulfilment, regardless of
between the different sectors and interests in a physical health status, or social and economic condi-
population. Such conflicts may arise, for ex- tions.
ample, from concerns about access to, use and Reference: modified definition.
distribution of resources, or constraints on indi- The goal of improving the quality of life,
vidual or organizational practices. Reconciling alongside preventing avoidable ill-health, has
such conflicts in ways which promote health become of increased importance in health pro-
may require considerable input from health pro- motion. This is particularly important in relation
motion practitioners, including the application of to meeting the needs of older people, the chroni-
skills in advocacy for health. cally sick, terminally ill, and disabled popula-
tions.
Network
A grouping of individuals, organizations and agencies Re-orienting health services
organized on a non-hierarchical basis around common
Health services re-orientation is characterized by a
issues or concerns, which are pursued proactively and
more explicit concern for the achievement of popula-
systematically, based on commitment and trust.
tion health outcomes in the ways in which the health
Reference: new definition. system is organized and funded. This must lead to a
WHO actively initiates and maintains several change of attitude and organization of health services,
health promotion networks around key settings which focuses on the needs of the individual as a whole
person, balanced against the needs of population
and issues. These include, for example, the inter- groups.
sectoral Healthy Cities network, networks of
Health Promoting Schools, and WHO country Reference: adapted from WHO (1986) Ottawa
networks for health promotion such as the WHO Charter.
Mega-Country Initiative. Networks of networks The Ottawa Charter also emphasizes the im-
are also being established. Examples include the portance of a health sector which contributes to
WHO (EURO) initiative `Networking the Net- the pursuit of health. Responsibility for achieving
works' and global networking initiatives for this is shared between all the health professions,
362 D. Nutbeam

health service institutions and government, which will directly benefit those taking the action,
alongside the contribution of individuals and it may also encompass mutual aid between indi-
communities served by the health sector. In viduals and groups. Self-help may also include
most cases this will require an expansion in self careÐsuch as self-medication and first aid in
health promotion and disease prevention action the normal social context of people's everyday
to achieve an optimal balance between invest- lives.
ments in health promotion, illness prevention,
diagnosis, treatment, care and rehabilitation ser- Settings for health
vices. Such an expanded role need not always be The place or social context in which people engage in
achieved through an increase in direct health daily activities in which environmental, organizational
system activity. Action by sectors other than the and personal factors interact to affect health and well-
health sector may be more effective in achieving being.
improved health outcomes. Governments need to Reference: new definition.
acknowledge the key role of the health sector in A setting is also where people actively use and
supporting such intersectoral action for health. shape the environment and thus create or solve
(See also Health Promoting Hospitals.) problems relating to health. Settings can nor-
mally be identified as having physical boundaries,
Risk behaviour a range of people with defined roles, and an
Specific forms of behaviour which are proven to be organizational structure.
associated with increased susceptibility to a specific Action to promote health through different
disease or ill-health. settings can take many different forms, often
Reference: modified definition. through some form of organizational develop-
Risk behaviours are usually defined as `risky' ment, including change to the physical environ-
on the basis of epidemiological or other social ment, to the organizational structure,
data. Changes in risk behaviour are major goals administration and management. Settings can
of disease prevention, and traditionally health also be used to promote health by reaching
education has been used to achieving these people who work in them, or using them to
goals. Within the broader framework of health gain access to services, and through the inter-
promotion, risk behaviour may be seen as a action of different settings with the wider com-
response, or mechanism for coping with adverse munity. Examples of settings include schools,
living conditions. Strategies to respond to this worksites, hospitals, villages and cities.
include the development of life skills, and cre-
ation of more supportive environments for health. Social capital
Social capital represents the degree of social cohesion
Risk factor which exists in communities. It refers to the processes
between people which establish networks, norms and
Social, economic or biological status, behaviours or
social trust, and facilitate coordination and coopera-
environments which are associated with or cause
tion for mutual benefit.
increased susceptibility to a specific disease, ill health,
or injury. Reference: new definition.
Reference: modified definition. Social capital is created from the myriad of
As is the case with risk behaviours, once risk everyday interactions between people, and is
factors have been identified, they can become the embodied in such structures as civic and religious
entry point or focus for health promotion strat- groups, family membership, informal community
egies and actions. networks, and in norms of voluntarism, altruism
and trust. The stronger these networks and
Self-help bonds, the more likely it is that members of a
community will cooperate for mutual benefit. In
In the context of health promotion, actions taken by
lay persons (i.e. not health professionals) to mobilize this way social capital creates health, and may
the necessary resources to promote maintain or restore enhance the benefits of investments for health.
the health of individuals or communities.
Social networks
Reference: modified definition. Social relations and links between individuals which
Although self-help is usually understood to may provide access to or mobilization of social support
mean action taken by individuals or communities for health.
 Health promotion glossary 363

Reference: modified definition. health has many dimensions, and may include:
A stable society is far more likely to have direct political action to develop and implement
established social networks which provide policies and regulations which help create sup-
access to social support. De-stabilizing influences portive environments; economic action, particu-
such as high unemployment, re-housing schemes, larly in relation to fostering sustainable economic
and rapid urbanization can lead to considerable development; and social action.
dislocation of social networks. In such circum-
stances action to promote health might focus on Sustainable development
support for re-establishing social networks. Sustainable development refers to the use of resources,
direction of investments, the orientation of technolo-
Social responsibility for health gical development, and institutional development in
Social responsibility for health is reflected by the ways which ensure that the current use of resources
actions of decision-makers in both public and private does not compromise the health and well-being of
sectors to pursue policies and practices which promote future generations.
and protect health.
Reference: adapted from WHO (1990) Gesund-
Reference: The Jakarta Declaration. heitsfoerderungs Glossar.
The policies and practices pursued by the In health promotion, sustainable development
public and private sectors should avoid harming is particularly important in terms of building
the health of individuals; protect the environment healthy public policy, and supportive environments
and ensure sustainable use of resources; restrict for health in ways which improve living condi-
the production of and trade in inherently harmful tions, support healthy lifestyles, and achieve
goods and substances, as well as discourage greater equity in health both now and in the
unhealthy marketing practices; safeguard the future.
citizen in the marketplace and the individual in
the workplace, and include equity-focused health
impact assessments as an integral part of policy A CK NO WL ED GE MEN TS
development. (See also Healthy public policy.)
Special thanks are due to Ursel Broesskamp-
Social support Stone for her support, advice and perseverance,
That assistance available to individuals and groups and to Desmond O'Byrne for his input and
from within communities which can provide a buffer advice in the preparation of the glossary, both
against adverse life events and living conditions, and of the Health Education and Health Promotion
can provide a positive resource for enhancing the Unit, WHO, Geneva; Ilona Kickbusch, Division
quality of life. of Health Promotion, Education and Commun-
Reference: modified definition. ication, WHO, Geneva, for her expert opinion
Social support may include emotional support, and guidance throughout the process of prepara-
information sharing and the provision of material tion and revision of the glossary; and to the
resources and services. Social support is now Regional Advisors for Health Promotion/Health
widely recognized as an important determinant Education of the WHO Regional Offices for
of health, and an essential element of social coordination of the review of the early drafts
capital. and helpful suggestions.

Supportive environments for health

BI BL IO G RA PH Y
Supportive environments for health offer people pro-
tection from threats to health, and enable people to
expand their capabilities and develop self-reliance in Original Glossary publication
health. They encompass where people live, their local Nutbeam, D., (1986) Health Promotion Glossary. Health
community, their homes, where they work and play, Promotion, 1, 113±127.
including people's access to resources for health, and
opportunities for empowerment. WHO formal publications and documents (in
order of publication)
Reference: Adapted from WHO (1991) Sundsvall Primary Health Care: Report of the International Conference
Statement on Supportive Environments. on Primary Health Care, Alma Ata, USSR (1978). WHO
Action to create supportive environments for Geneva.
364 D. Nutbeam
New Approaches to Health Education in Primary Health Care: Advocacy Strategies for Health and Development: Development
Report of WHO Expert Committee (1983). Technical Communication in Action (1995). WHO, Geneva.
Report Series 690. WHO, Geneva. Yanuca Island Declaration (1995). WHO (WPRO), Manila.
Glossary of Terms used in `Health for All' Series (1984). WHO, Renewing the Health for All Strategy: Guiding Principles and
Geneva. Essential Issues for the Elaboration of a Policy for Equity,
Ottawa Charter for Health Promotion (1986). WHO, Geneva. Solidarity, and Health (1995). WHO, Geneva.
The Adelaide Recommendations on Healthy Public Policy Equity in Health and Health Care (1996). WHO, Geneva.
(1988). WHO, Geneva. Health Promoting Schools: Regional Guidelines (1996). WHO
Gesundheitsfoerderungs Glossar (Health Promotion Glossary (WPRO), Manila.
Produced for the `Investment in Health Conference' in Kickbusch, I. (1997) Health Promoting EnvironmentsÐthe
German and English) (1990). WHO (EURO), Copenhagen. next steps, 1997. Australian and New Zealand Journal of
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(1990). WHO, Geneva. WHO Expert Committee on Comprehensive School Health
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(1991). WHO, Geneva. Schools; Report of a WHO Expert Committee on Compre-
Budapest Declaration on Health Promoting Hospitals (1991). hensive School Health Education and Promotion, WHO
WHO (EURO), Copenhagen. Technical Report Series. WHO, Geneva.
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Geneva. All in the 21st Century, WHO/PPE/PAC/97.6 (1997). WHO,
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Research: Towards a New Social Epidemiology. WHO The Jakarta Declaration on Health Promotion in the 21st
(EURO), Copenhagen. Century, HPR/HEP/4ICHP/BR/97.4 (1997). WHO,
Life skills education in schools (1993). Unpublished document Geneva.
WHO/MNH/PSF/93.7A. WHO, Geneva.
Terminology for the European Health Policy Conference: A For further information on relevant publications
glossary with equivalents in French, German and Russian refer to:
(1994). WHO (EURO), Copenhagen.
Dhillon, H. S. and Philip, L. (1994) Health Promotion and WHO (1997) Health Promotion Bibliography. WHO, Geneva.
Community Action for Health in Developing Countries. Available on the Internet via http://www.who.ch/hep
WHO, Geneva.

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