**5. Health promotion research in Africa**

*Public Health in Developing Countries - Challenges and Opportunities*

apprehended as contributing to the health of the communities [23].

Traditionally there are five approaches utilized in health promotion. These are medical (the focus here is to make people free from medically defined diseases and afflictions; it is mainly anchored on prevention strategies and the role of the medical practitioner or expert in ensuring that the patients comply with recommendations); behavioural change (behaviour modification approach that recognizes that people's behaviour and lifestyles can be changed in order to enable them attain good health, i.e., facilitate adoption of healthy lifestyle); educational (provision of information and knowledge that enable understanding of health issues and build awareness for informed decision-making and choice among people); client-centred (in this situation health practitioners work with clients in order to identify what they know about a given disease and take appropriate action; emphasis on perceiving the client as equal and building the clients self-empowerment that enable them make good choices and control their health outcomes); and societal change (the focus here is on the society or community rather than the individual and seeks to change or modify both the physical and social environments in order to make them

The conventional health promotion methods (modes of operationalizing health promotion and achieving its goals) include health education (the conscious and systematic effort at providing education or knowledge to people on particular and general aspects of health; it is about enabling people through proper and right knowledge on what to do and how to do it; it is empowering and improving people's capacity to act with regard to their health issues and conditions), information, communication (the above three are often captured in the popular acronym IEC), social mobilization, mediation, community theater and advocacy and lobbying. However, while these methods are okay in differing contexts, a decision on the specific medium to use should be guided by both environment (community conditions) and the nature of the health issue involved. The use of more than one method in any given case is highly recommended especially in Africa where there are broad inequalities in access to social goods and the media. The increasing use of social

**4. Approaches to health promotion**

consistent with or conducive to good health).

well as the reasonable funding demanded by any effective public health system. As Harrison opines health promotion "requires concerted, sophisticated and integrated political action to bring about change and requires professionals concerned with public health to engage with the politics of systems and organizations" [5], 165. Therefore, health promotion seeks to empower and transform communities by getting them involved in activities that influence public health especially through agenda setting, lobbying and advocacy, consciousness raising and social education [11, 22]. All these are accomplished on terms that are either defined or strictly affected by the socio-economic realities of the people themselves. By its emphasis on the community, health promotion has a heavy sociological frame that prioritizes the values of society as well as mobilization and solidarity in the quest for good and sustainable health. It thus makes assumption that individual members of the society would give equal weight to their own health and the health of their neighbors. In other words, it is often anchored on the uncanny assumption that the health of the individual member of a given society is intertwined with the health of the community as a collective. This means the reference point of health promotion is that one's health is as good as the health of the members of the community or society as a whole, i.e., common health destiny. Therefore, such things as community empowerment, community competence and overwhelming sense of community are all

**58**

There is an undeniable need to give high priority to health promotion research in Africa. Such research should aim at enabling a realistic and focused achievement of the goals of health promotion. Broadly, health promotion aims inter alia at:


According to the WHO [24] Health Promotion Strategy for the African Region, the contributions of health promotion to the achievement of health objectives include increasing individual knowledge and skills especially through IEC; strengthening community action through the use of social mobilization; enabling the emergence of environments supportive and protective of health by making optimal use of mediation and negotiation; enabling the development of public policies, legislation and fiscal controls which enhance and support health and overall development using advocacy and lobbying; and making prevention and consumer needs the core focus of health services delivery. All these can be positively influenced by research and studies which evaluate the effectiveness of what has been done as well as explore new strategies suitable to the socio-environmental context in question.

However, while research is very critical to achieving the goals of health promotion, it should be concise and focus essentially on the priority health programmes which have been identified by the WHO for the continent. Some of such programmes include the Global Fund for Malaria, HIV/AIDS and Tuberculosis, Immunization, Mental Health, the Tobacco Free Initiative and Reproductive Health as well as the fight against recurrent scourge of Ebola, etc. Such research should focus on identifying effective health promotion approaches and communication media to embody and convey the outcomes to communities through community participation; the extent or effectiveness of these means and seeking to still improve overall programme effectiveness and sustainability. Therefore, health promotion research should focus on ascertaining goals/outcomes of health promotion (to guide policy), provide reliable conditions associated with these outcomes or goals, precisely define the changes intended and delineate reliable mechanisms and indicators of M and E of health promotion strategies in specific country/community contexts.

The importance of research is essentially derived from the fact that it calls attention to the need for verification and evidence-based activities in health promotion. These are without doubt the ways of knowing if real empowerment and enabling has been achieved in the process. Thus,

*Health promotion is about enabling people to improve their health; and secondly, evidence relevant to health promotion should bear directly on factors that support or prevent enablement and empowerment (determinants of health) activities that support enablement and empowerment (health promotion) and assessing whether these activities have been successful (evaluation of health promotion). [25], p. 357*

The above clearly suggest that health promotion should be anchored on evidence or should rest on experience and reality regarding what works or what is possible and effective in any context. In this manner, "evidence-based health promotion involves explicit application of quality research evidence when making decisions" [26], p. 126. Research is even more foundational in health promotion since health promotion efforts need to be anchored on agreed definitions and values of health promotion. As Seedhouse contends the failure to be explicit about definitions and values generates conceptual confusion in research as well as sloppy practice [27].

The evaluation of health promotion which should be a core research activity may be based on the three main forms of evidence/knowledge associated with health promotion [28]: instrumental (controlling social and physical environments), interactive (understanding of diseases/health issues; lived experiences; solidarity) and critical (reflection and action; raising consciousness regarding causes and means of overcoming them). These three evidences are anchored on the given scientific/philosophical traditions, viz. instrumental (positivism, quantitative, experimental, scientific knowledge), interactive (constructivist, naturalistic, ethnographic/qualitative knowledge) and critical (materialist, structural and feminist theory).

There is also an overwhelming need for health promotion research to be aware of the difference between health promotion outcomes and health outcomes. Health outcomes crudely imply the consequences or benefits of healthcare delivery (e.g., reduction of mortality rate) related to a disease (which may be the case in spite of an increment in number of those affected by the disease). But health promotion outcomes signify the form of control and attitudinal re-orientation groups and individuals adopt in facing a given disease which may impact on the number of people affected by the disease and improve attitudes and behaviour towards those affected by the disease. Health promotion outcomes can be seen directly through community members' perception and interpretations of a given health issue which makes the achievement of control possible.

Health promotion research should utilize both quantitative and qualitative methods. In addition to complementing quantitative methods in health promotion research, qualitative research enables the researcher reach the heart of issues in engagement with community members. In Africa, where a good percentage of the population are still domiciled in the rural areas, qualitative approach offers the possibility of profound insights into the why and how of health behaviors which may not be possible or easily achieved with the quantitative or traditional biomedical approaches. As a result, "the increasing popularity of qualitative methods is as a result of perceived failure of traditional methods to provide insights into the determinants – both structural and personal – of whether people pursue or do not pursue health-promoting actions" [25], p. 359*.*

#### **6. Challenges to health promotion in Africa**

It is important to recognize that in spite of apparent good intentions, health promotion can actually generate negative or counterproductive effects when not

**61**

*Health Promotion and Its Challenges to Public Health Delivery System in Africa*

well managed. Thus, "negative outcomes occur where professionally paternalistic and disempowering health policy decisions force health-related outcomes that are irrelevant to sustained community development and are not based on or resourced according to the social reality of the community" [11], p. 315. The above sentiments caution one against embarking on health promotion activities and initiatives that are not anchored on the health realities of the community concerned. Often, overzealous health professionals unintentionally betray the health priorities of communities by assuming knowledge of all there is to know about the health situations

Perhaps a critical shortfall of some health promotion activities and processes is the adoption of what can be termed the pathogenic paradigm which over-relies on risk instead of emphasizing protective mechanisms. This essentially entails a focus on the failure of communities and individuals to avoid disease or their apparent susceptibility to diseases instead of seeking to unleash their potential and capacity to engender and sustain good health and development. It is an approach that relies too much on health practitioners and experts and hardly gives voice to the people

Generally health promotion in Africa suffers from some of the debilitating challenges which confront the practice of health promotion broadly in many countries

• Poor definition and rudimentary elaboration of expected health outcomes

• Ambiguous elaboration of factors and conditions to be targeted in health

• Lack of capacity (or inadequate capacity) to develop, implement and evaluate

• Low political will and commitment to health promotion programmes as well as

The above challenges have implications for research in health promotions in the continent. There is no gainsaying the need for health promotion to be evidence based because essentially it is the only way to make it responsive to the health needs

Health promotion combines varied but complementary indicators like legislation, health finance including fiscal measures and taxation, gender inclusiveness, mapping of priorities and organizational change. In spite of their differences, these issues are in reality intertwined or systematically connected in the sense that, for the public health system to function well and optimally, there should be a synergy

*DOI: http://dx.doi.org/10.5772/intechopen.91859*

and their own knowledge cum realities.

health promotion programmes

• Underdeveloped sectoral collaboration

in the continent. These challenges, among others, include:

• Ambiguity of health promotion policies and guidelines

institutional corruption and resource mismanagement

**7. Resituating and reinforcing health promotion in Africa**

• A general context of inadequate investment in health promotion

and needs of the people.

promotions

and interests of the people.

between these indicators. Briefly:

#### *Health Promotion and Its Challenges to Public Health Delivery System in Africa DOI: http://dx.doi.org/10.5772/intechopen.91859*

well managed. Thus, "negative outcomes occur where professionally paternalistic and disempowering health policy decisions force health-related outcomes that are irrelevant to sustained community development and are not based on or resourced according to the social reality of the community" [11], p. 315. The above sentiments caution one against embarking on health promotion activities and initiatives that are not anchored on the health realities of the community concerned. Often, overzealous health professionals unintentionally betray the health priorities of communities by assuming knowledge of all there is to know about the health situations and needs of the people.

Perhaps a critical shortfall of some health promotion activities and processes is the adoption of what can be termed the pathogenic paradigm which over-relies on risk instead of emphasizing protective mechanisms. This essentially entails a focus on the failure of communities and individuals to avoid disease or their apparent susceptibility to diseases instead of seeking to unleash their potential and capacity to engender and sustain good health and development. It is an approach that relies too much on health practitioners and experts and hardly gives voice to the people and their own knowledge cum realities.

Generally health promotion in Africa suffers from some of the debilitating challenges which confront the practice of health promotion broadly in many countries in the continent. These challenges, among others, include:


The above challenges have implications for research in health promotions in the continent. There is no gainsaying the need for health promotion to be evidence based because essentially it is the only way to make it responsive to the health needs and interests of the people.

## **7. Resituating and reinforcing health promotion in Africa**

Health promotion combines varied but complementary indicators like legislation, health finance including fiscal measures and taxation, gender inclusiveness, mapping of priorities and organizational change. In spite of their differences, these issues are in reality intertwined or systematically connected in the sense that, for the public health system to function well and optimally, there should be a synergy between these indicators. Briefly:

*Public Health in Developing Countries - Challenges and Opportunities*

*Health promotion is about enabling people to improve their health; and secondly, evidence relevant to health promotion should bear directly on factors that support or prevent enablement and empowerment (determinants of health) activities that support enablement and empowerment (health promotion) and assessing whether these activities have been successful (evaluation of health promotion). [25], p. 357*

The above clearly suggest that health promotion should be anchored on evidence or should rest on experience and reality regarding what works or what is possible and effective in any context. In this manner, "evidence-based health promotion involves explicit application of quality research evidence when making decisions" [26], p. 126. Research is even more foundational in health promotion since health promotion efforts need to be anchored on agreed definitions and values of health promotion. As Seedhouse contends the failure to be explicit about definitions and values generates conceptual confusion in research as well as sloppy practice [27]. The evaluation of health promotion which should be a core research activity may be based on the three main forms of evidence/knowledge associated with health promotion [28]: instrumental (controlling social and physical environments), interactive (understanding of diseases/health issues; lived experiences; solidarity) and critical (reflection and action; raising consciousness regarding causes and means of overcoming them). These three evidences are anchored on the given scientific/philosophical traditions, viz. instrumental (positivism, quantitative, experimental, scientific knowledge), interactive (constructivist, naturalistic, ethnographic/qualitative knowledge) and critical (materialist, structural and

There is also an overwhelming need for health promotion research to be aware of the difference between health promotion outcomes and health outcomes. Health outcomes crudely imply the consequences or benefits of healthcare delivery (e.g., reduction of mortality rate) related to a disease (which may be the case in spite of an increment in number of those affected by the disease). But health promotion outcomes signify the form of control and attitudinal re-orientation groups and individuals adopt in facing a given disease which may impact on the number of people affected by the disease and improve attitudes and behaviour towards those affected by the disease. Health promotion outcomes can be seen directly through community members' perception and interpretations of a given health issue which makes the

Health promotion research should utilize both quantitative and qualitative methods. In addition to complementing quantitative methods in health promotion research, qualitative research enables the researcher reach the heart of issues in engagement with community members. In Africa, where a good percentage of the population are still domiciled in the rural areas, qualitative approach offers the possibility of profound insights into the why and how of health behaviors which may not be possible or easily achieved with the quantitative or traditional biomedical approaches. As a result, "the increasing popularity of qualitative methods is as a result of perceived failure of traditional methods to provide insights into the determinants – both structural and personal – of whether people pursue or do not

It is important to recognize that in spite of apparent good intentions, health promotion can actually generate negative or counterproductive effects when not

**60**

feminist theory).

achievement of control possible.

pursue health-promoting actions" [25], p. 359*.*

**6. Challenges to health promotion in Africa**

#### **7.1 Legislation**

This revolves around having the political will to make and drive through policies and laws that improve and sustain healthcare delivery. It also involves public health sector governance and leadership which aim at ensuring that only competent and qualified people lead the sector and that activities are governed by a democratic and free process which place emphasis on human rights, dignity and self-worth of all stakeholders.

#### **7.2 Finance**

Without doubt efficient health promotion and by implication the entire health delivery system cannot function without finance. In fact, the extent and impact of health promotion depend to a significant extent on the availability of funds. The problem of finance is especially critical in developing nations in Africa where political corruption and competing needs whittle down whatever gets to health from the yearly appropriation of government. However, there is a need to understand that a lot needs to be done in terms of the fiscal policies in these nations in order to achieve the desire for good health and improved life expectancy. In other words, the process of fiscal policymaking and budgetary allocation should prioritize health promotion and health delivery in these countries.

#### **7.3 Organizational change**

There is no gainsaying the fact that the health system as a whole is dynamic especially so in Africa where apart from battling known ailments new ones (or novel presentation of the old ailments) spring up now and then. The above entails that the health system calls for dynamic organizational setting that is robust enough to deal with changes while making improvements in the system. There is apparently no denying the fact that health promotion as a critical component of health delivery would benefit from organizational change. This is particularly so in the face of the reality that health promotion in most of the continent is still below the expectation. This is not to deny that health promotion has worked well in specific instances like the HIV/AID scourge and maternal health. However, such grab and slash system which focuses on only one of such delimited issues in the system cannot be seen as either robust or effective in the long run.

#### **7.4 Gender inclusiveness**

There is an obvious need to 'en-gender' health promotion as a very critical issue in Africa. This would entail ensuring that those involved in health promotion ensure that in all key phases of health promotion (planning, implementation and evaluation) women and men should be equal partners and collaborators. Gender, in this case, while calling attention to the needs of women, should also ensure that the men are not left behind even in approaching health issues traditionally seen as the concerns of women. Typical example here is in the area of family planning or reproductive health which demands the active collaboration or participation of both men and women to achieve desired results.

#### **7.5 Mapping of priorities**

For the WHO [24], the priority interventions in Africa in respect of health promotions include capacity building, development of plans, incorporation of health promotion components in non-health sectors and strengthening of priority

**63**

be programmed as such.

*Health Promotion and Its Challenges to Public Health Delivery System in Africa*

programmes using health promotion interventions. These essentially mean pursuing health promotion through capacity building, action planning, advocacy and multisectoral orientation. They are also in tune with relating to the determinants of health promotion in the continent. These include socio-economic conditions and physical (environment), biological, and behavioral lifestyles which impact on health in Africa. Countries can be encouraged to map out their priorities taking into consideration such factors as disease and financial burdens, threats, intervention tools and agencies, acuity, management capabilities, persistent challenges, etc.

Generally, there is a need for stepping up health promotion research in Africa in the areas of family and reproductive health targeting such issues as VVF, antenatal care, diabetes, cardiovascular issues, new disease forms/resurgence of old diseases (including Ebola), etc. especially in terms of communicating with those who are marginal to the formal sector of the society or who are less privileged by virtue of education, economic opportunities or physical/mental challenges, etc. in both urban and rural contexts. Health promotion can profit from an acute awareness of the fact that what works in one socio-geographical setting may not work in another since no two societies are exactly the same. This would entail designing programmes that even where the general principles or goals remain the same embody recognition

of the socio-geographical peculiarities of the society/community concerned.

way of pursuing health promotion goals without elaborate budget.

cost and save time, there should be incorporation of both needs assessment and evaluation into ongoing health promotion activities. This approach offers a smart

In addition to media practitioners, there should be health programme or intervention specific to health promotion capacity building for different cadres of public sector workers. Such capacity building or training should be anchored on acute awareness of current research trends and best practices globally. There should also be increased attention to the need for specific health promotion for underrepresented health issues and priority to non-communicable diseases should be targeted. It should also improve capacity on how to incorporate methods of targeting

members of the society marginal or vulnerable within each country context.

Given the usual paucity of funds in the continent, it makes sense that to minimize

In spite of country differences and specific structural challenges, there is a need to build a culture of sharing and documenting outcomes and evidences of health promotion between different countries and organizations. This is a step towards achieving the desirable goal of multinational coordination especially for infectious diseases and epidemics. Equally, African nations need to invest more in capacity building for media and theater practitioners in both private and public sectors on health promotion. There is no gainsaying the media's crucial role in health information dissemination. Actually, health promotion is largely media driven and should

*DOI: http://dx.doi.org/10.5772/intechopen.91859*

**8. Conclusion and recommendations**

*Health Promotion and Its Challenges to Public Health Delivery System in Africa DOI: http://dx.doi.org/10.5772/intechopen.91859*

programmes using health promotion interventions. These essentially mean pursuing health promotion through capacity building, action planning, advocacy and multisectoral orientation. They are also in tune with relating to the determinants of health promotion in the continent. These include socio-economic conditions and physical (environment), biological, and behavioral lifestyles which impact on health in Africa. Countries can be encouraged to map out their priorities taking into consideration such factors as disease and financial burdens, threats, intervention tools and agencies, acuity, management capabilities, persistent challenges, etc.

### **8. Conclusion and recommendations**

*Public Health in Developing Countries - Challenges and Opportunities*

This revolves around having the political will to make and drive through policies and laws that improve and sustain healthcare delivery. It also involves public health sector governance and leadership which aim at ensuring that only competent and qualified people lead the sector and that activities are governed by a democratic and free process which place emphasis on human rights, dignity and self-worth of all stakeholders.

Without doubt efficient health promotion and by implication the entire health delivery system cannot function without finance. In fact, the extent and impact of health promotion depend to a significant extent on the availability of funds. The problem of finance is especially critical in developing nations in Africa where political corruption and competing needs whittle down whatever gets to health from the yearly appropriation of government. However, there is a need to understand that a lot needs to be done in terms of the fiscal policies in these nations in order to achieve the desire for good health and improved life expectancy. In other words, the process of fiscal policymaking and budgetary allocation should prioritize health promotion

There is no gainsaying the fact that the health system as a whole is dynamic especially so in Africa where apart from battling known ailments new ones (or novel presentation of the old ailments) spring up now and then. The above entails that the health system calls for dynamic organizational setting that is robust enough to deal with changes while making improvements in the system. There is apparently no denying the fact that health promotion as a critical component of health delivery would benefit from organizational change. This is particularly so in the face of the reality that health promotion in most of the continent is still below the expectation. This is not to deny that health promotion has worked well in specific instances like the HIV/AID scourge and maternal health. However, such grab and slash system which focuses on only one of such delimited issues in the system cannot be seen as

There is an obvious need to 'en-gender' health promotion as a very critical issue in Africa. This would entail ensuring that those involved in health promotion ensure that in all key phases of health promotion (planning, implementation and evaluation) women and men should be equal partners and collaborators. Gender, in this case, while calling attention to the needs of women, should also ensure that the men are not left behind even in approaching health issues traditionally seen as the concerns of women. Typical example here is in the area of family planning or reproductive health which demands the active collaboration or participation of both

For the WHO [24], the priority interventions in Africa in respect of health promotions include capacity building, development of plans, incorporation of health promotion components in non-health sectors and strengthening of priority

**7.1 Legislation**

**7.2 Finance**

and health delivery in these countries.

either robust or effective in the long run.

men and women to achieve desired results.

**7.4 Gender inclusiveness**

**7.5 Mapping of priorities**

**7.3 Organizational change**

**62**

Generally, there is a need for stepping up health promotion research in Africa in the areas of family and reproductive health targeting such issues as VVF, antenatal care, diabetes, cardiovascular issues, new disease forms/resurgence of old diseases (including Ebola), etc. especially in terms of communicating with those who are marginal to the formal sector of the society or who are less privileged by virtue of education, economic opportunities or physical/mental challenges, etc. in both urban and rural contexts. Health promotion can profit from an acute awareness of the fact that what works in one socio-geographical setting may not work in another since no two societies are exactly the same. This would entail designing programmes that even where the general principles or goals remain the same embody recognition of the socio-geographical peculiarities of the society/community concerned.

Given the usual paucity of funds in the continent, it makes sense that to minimize cost and save time, there should be incorporation of both needs assessment and evaluation into ongoing health promotion activities. This approach offers a smart way of pursuing health promotion goals without elaborate budget.

In spite of country differences and specific structural challenges, there is a need to build a culture of sharing and documenting outcomes and evidences of health promotion between different countries and organizations. This is a step towards achieving the desirable goal of multinational coordination especially for infectious diseases and epidemics. Equally, African nations need to invest more in capacity building for media and theater practitioners in both private and public sectors on health promotion. There is no gainsaying the media's crucial role in health information dissemination. Actually, health promotion is largely media driven and should be programmed as such.

In addition to media practitioners, there should be health programme or intervention specific to health promotion capacity building for different cadres of public sector workers. Such capacity building or training should be anchored on acute awareness of current research trends and best practices globally. There should also be increased attention to the need for specific health promotion for underrepresented health issues and priority to non-communicable diseases should be targeted. It should also improve capacity on how to incorporate methods of targeting members of the society marginal or vulnerable within each country context.

*Public Health in Developing Countries - Challenges and Opportunities*
