IMPLEMENTING CHANGES IN PUBLIC HEALTH AND PUBLIC

HEALTH PROMOTION

By
SAFINA USMAN
[email protected]
MSC. PUBLIC HEALTH

JOIN PROFESSIONALS TRAINING AND SUPPORT

INTERNATIONAL
KANKIA STUDY CENTRE, KATSINA STATE

ABSTRACT
There is an indication that the Health promotion perceptions among community
in Nigeria need changes. Nigerian public health educators and pharmacists in
this survey perceived an extended role in health promotion, especially
medication-related activities. This is consistent with the philosophy of primary
healthcare and pharmaceutical care. However, Reviews of research on
changing a variety of health behaviors have shown that interventions based on
theory or theoretical constructs are more effective than are those not using
theory. Furthermore, the mechanisms that explain the larger effects have not
been studied. The most often used theories of health behavior are social
cognitive theory (SCT), the trans-theoretical model (TTM)/stages of change, the
health belief model (HBM), and the theory of planned behavior (TPB). The
most often mentioned theoretical model that has not been fully applied in
research and practice is the social ecological model. There are many needs to
better articulate, apply, and evaluate this important and promising model.
Health-promotion and public health researchers and practitioners should both
question and improve how thoroughly we use theory, how we turn theories into
interventions, how we test theories, and what conclusions we draw from
research. Health-promotion programs that address significant public health
problems including health disparities should complement individually oriented
intervention models with strategies and models to develop healthier policies,
systems, and environments.
1
Introduction

One of the key concerns in Health care management is management of change

and health care professionals are obligated both to acquire and to maintain the

expertise needed to undertake their professional tasks, and all are obligated to

undertake only those tasks that are within their competence (Al-Abri RK, 2007).

Moreover, change occurs continuously around us. We may want to support it,

be indifferent to it, and be passive or participate in it. The pace of change has

increased dramatically.

Managing change is about handling the complexity of the process. It is about

evaluating, planning and implementing operations, tactics and strategies and

making sure that the change is worthwhile and relevant. Managing change is a

complex, dynamic and challenging process. It is never a choice between

technological or people-oriented solutions but a combination of all.

Effective change has been characterized as unfreezing old behaviours,

introducing new ones, and re-freezing them. Change may be continuous,

sporadic, occasional, or rare. Predictable change allows time for preparation,

whereas unpredictable change is more difficult to respond to effectively. Since

changes in healthcare occur so rapidly, they are less likely to be predictable.

Umiker W (1998)

2
The only sustainable competitive advantage today is the ability to change,

adapt, and evolve - and to do it better than the competition. Failure rates are

associated to a number of different factors such as lack of vision and

commitment from senior management, limited integration with other systems

and processes in the organization, and ill-conceived implementation plans. If

organizations are to experience a greater level of success in their development

efforts, managers and executives need to have a better framework for thinking

about change and an understanding of the key issues which accompany change

management.

Even if change is endorsed, employees want to understand why change is

happening and how they will be affected. Layoffs or other organizational

changes can lead to paranoia, confusion, anger and insecurities under the

auspices of change.

Promoting change is both demanding and fatiguing. Bringing about change

requires the manager to challenge the precedent, and requires perseverance

against the habits and norms of established behaviours. Bringing about change

takes time and requires the commitment of time on the part of the manager

(Weiss WH, 1998). The manager must know the values that matter and focus on

changing those as opposed to reacting to every invitation for change. She/he

must be clear about what is important and develop responses and proactive

actions accordingly. Nelson EC, 1998

3
Organizations that employ large numbers of professionals will not perform well

if they become overly bureaucratic. Steiner stated that organizations that are

known to be bureaucratized and hierarchical are less flexible, less amenable to

change and less likely to empower staff. Steiner C 2001 opines that an

organization will not get full value from its professional employees if it insists

that they do only what they are told. Therefore, leaders have to learn how to

manage change, rather than change manages them in order to move forward

with success. Coram and Burnes argued that there is no "one best way" to

manage change in an organization, and that public sector organizations need to

introduce an approach to organization change which matches their requirements

and situation (Coran R, 2001). It has to be admitted that change in management

will keep happening. In addition, leaders need to understand the change process

and issues that are involved with it in order to have the capability to lead and

manage change and improve efforts effectively (Davies C, 2000). They must

learn to overcome obstacles and cope with the chaos that naturally exists during

the complex process of change (McCalman J., 2001). Leaders should help

employees and other stakeholders structure and build effective teams by

developing new organizational structures and creating a shared vision that

focuses on authentic employees’ output. Such inspired and informed leadership

is critical and essential for organizations to be successful.

4
Establishing a clear vision about the direction of the change process is another

key element for assuring successful change (Klunk SW., 1997). Measuring and

monitoring outcomes of the change process is essential for recognizing whether

or not the change process has fulfilled its purposes (Leatt P, Baker GR et-al,

1997). Since change is continuing to happen in organizations and associated

modifications are taking place, it is important for those who are in charge of the

change process to record and focus on the emerging problems due to change.

This will help avoid them in the future so that the new administration system

will help to manage the change in the proper and best manner.

Literature Review

Public health has been defined as "the science and art of preventing disease”,

prolonging life and improving quality of life through organized efforts and

informed choices of society, organizations (public and private),communities and

individuals. Charles-Edward Amory (2000)

Analyzing the determinants of health of a population and the threats it faces is

the basis for public health. Rosen, George (2015). The public can be as small as

a handful of people or as large as a village or an entire city; in the case of a

pandemic it may encompass several continents. The concept of health takes into

account physical, psychological, and social well-being. Public health is an

interdisciplinary field. For example, epidemiology, biostatistics, social sciences

and management of health services are all relevant. Other important sub-fields
5
include environmental health, community health, behavioral health, health

economics, public policy, mental health, health education, health politics,

occupational safety, disability, gender issues in health, and sexual and

reproductive health. Rosen, George (2015) Public health, together with primary

care, secondary care, and tertiary care, is part of a country's overall health care

system. Public health is implemented through the surveillance of cases and

health indicators, and through the promotion of healthy behaviors. Common

public health initiatives include promotion of hand-washing and breastfeeding,

delivery of vaccinations, suicide prevention, smoking cessation, obesity

education, increasing healthcare accessibility and distribution of condoms to

control the spread of sexually transmitted diseases. There is a significant

disparity in access to health care and public health initiatives between

developed countries and developing countries, as well as within developing

countries. In developing countries, public health infrastructures are still

forming. There may not be enough trained health workers, monetary resources

or, in some cases, sufficient knowledge to provide even a basic level of medical

care and disease prevention. Rosen, George (2015)

A major public health concern in developing countries is poor maternal and

child health, exacerbated by malnutrition and poverty. From the beginnings of

human civilization, communities promoted health and fought disease at the

population level. Rosen, George (2015). In complex, pre-industrialized

6
societies, interventions designed to reduce health risks could be the initiative of

different stakeholders, such as army generals, the clergy or rulers. Great Britain

became a leader in the development of public health initiatives, beginning in the

19th century, due to the fact that it was the first modern urban nation

worldwide. Merson MH, et al. (2009)

The public health initiatives that began to emerge initially focused on sanitation

(for example, the Liverpool and London sewerage systems), control of

infectious diseases (including vaccination, quarantine ) and an evolving

infrastructure of various sciences, e.g. statistics, microbiology, epidemiology,

sciences of engineering. Merson MH, et al. (2009)

Related terms

Public health is related to global health which is the health of populations in the

worldwide context. It has been defined as "the area of study, research and

practice that places a priority on improving health and achieving equity in

health for all people worldwide". International health is a field of health care,

usually with a public health emphasis, dealing with health across regional or

national boundaries. Wang, Fahui (2 January 2020) Public health is not the

same as public healthcare (publicly funded health care).

7
Purposes

The purpose of a public health intervention is to prevent and mitigate diseases,

injuries and other health conditions. The overall goal is to improve the health of

populations and increase life expectancy.

Characteristics and components

Public health is a complex term, composed of many elements and different

practices. It is a multi-faceted interdisciplinary field, multi-faceted (Merson

MH, et al. 2009). For example, epidemiology, biostatistics, social sciences and

management of health services are all relevant. Other important sub-fields

include environmental health, community health, behavioral health, health

economics, public policy, mental health, health education, health politics,

occupational safety, disability, gender issues in health, and sexual and

reproductive health. Modern public health practice requires multidisciplinary

teams of public health workers and professionals. Teams might include

epidemiologists, biostatisticians, physician assistants, public health nurses,

midwives, medical microbiologists, pharmacists, economists, sociologists,

geneticists, data managers, environmental health officers (public health

inspectors), bioethicists, gender experts, sexual and reproductive health

specialists, physicians, and even veterinarians.

8
The elements and priorities of public health have evolved over time, and are

continuing to evolve. Different regions in the world can have different public

health concerns at a given time. Common public health initiatives include

promotion of hand-washing and breastfeeding, delivery of vaccinations, suicide

prevention, smoking cessation, obesity education, increasing healthcare

accessibility and distribution of condoms to control the spread of sexually

transmitted diseases.

Methods

Public health aims are achieved through surveillance of cases and the promotion

of healthy behaviors, communities and environments. Analyzing the

determinants of health of a population and the threats it faces is the basis for

public health.

Many diseases are preventable through simple, nonmedical methods. For

example, research has shown that the simple act of hand-washing with soap can

prevent the spread of many contagious diseases. In other cases, treating a

disease or controlling a pathogen can be vital to preventing its spread to others,

either during an outbreak of infectious disease or through contamination of food

or water supplies. Public health communications programs, vaccination

programs and distribution of condoms are examples of common preventive

public health measures. Public health, together with primary care, secondary

care, and tertiary care, is part of a country's overall health care system. Many

9
interventions of public health interest are delivered outside of health facilities,

such as food safety surveillance, distribution of condoms and needle-exchange

programs for the prevention of transmissible diseases. Public health plays an

important role in disease prevention efforts in both the developing world and in

developed countries through local health systems and non- governmental

organizations. Public health requires Geographic Information Systems (GIS)

because risk, vulnerability and exposure involve geographic aspects.

Ways of implementing changes in public health

Healthcare organizations often have a vision where they want to be, but they

end of having a gap between where they are know and where they want to be in

the future. To plan change, the organization and employees must realistically

access the current strengths and weaknesses. This will help identify gap. Gaps

can be identified by asking clients, taking what clients complain about

seriously, and asking employees. This can be done by interviews and surveys.

Once you know what needs to be changed, you can plan your short-term and

long-term goals or objectives. It is important to include employees as much as

possible when developing goals, objectives, planning and implementing the

change. The more people consulted, the more information will be available for

developing change plans.

Knaus, Michael A. 2009.

10
The following are the do's:-

1. Invite suggestion from everybody possible.

2. Hold frequent formal and informal meetings.

3. Involve teams in planning and implementation.

4. Manage individual's expectation of the change with care.

5. Communicate, communicate and communicate during change.

The following are the don’ts:-

1. Do not coerce individual in to change.

2. Do not keep unnecessary secrets from employees about change.

3. Do not leave any individual isolated.

4. Do not break promises you made about change.

Conceptualizing Public Health Promotion

Health promotion is a behavioral social science that draws from the biological,

environmental, psychological, physical and medical sciences to promote health

and prevent disease, disability and premature death through education-driven

voluntary behavior change activities. Health promotion is the development of

individual, group, institutional, community and systemic strategies to improve

health knowledge, attitudes, skills and behavior.

Progress in public health and community-based interventions has been

hampered by the lack of a comprehensive evaluation framework appropriate to

11
such programs. Multilevel interventions that incorporate policy, environmental,

and individual components should be evaluated with measurements suited to

their settings, goals, and purpose. In this commentary, the authors propose a

model (termed the RE-AIM model) for evaluating public health interventions

that assesses 5 dimensions: reach, efficacy, adoption, implementation, and

maintenance. These dimensions occur at multiple levels (e.g., individual, clinic

or organization, community) and interact to determine the public health or

population-based impact of a program or policy. The authors discuss issues in

evaluating each of these dimensions and combining them to determine overall

public health impact. Failure to adequately evaluate programs on all 5

dimensions can lead to a waste of resources, discontinuities between stages of

research, and failure to improve public health to the limits of our capacity.

Six Components Necessary for Effective Public Health Program

Implementation

Public health programs succeed and survive if organizations and coalitions

address 6 key areas.

1) Innovation to develop the evidence base for action;

2) A technical package of a limited number of high-priority, evidence-based

interventions that together will have a major impact;

3) Effective performance management, especially through rigorous, real-time

monitoring, evaluation, and program improvement;

12
4) Partnerships and coalitions with public-and private-sector organizations;

5) Communication of accurate and timely information to the health care

community, decision makers, and the public to effect behavior change and

engage civil society; and

6) Political commitment to obtain resources and support for effective action.

Programs including smallpox eradication, tuberculosis control, tobacco

control, polio eradication, and others have made progress by addressing

these 6 areas.

The Role of Behavioral Science Theory in Development and Implementation

of Public Health Interventions:

Increasing evidence suggests that public health and health-promotion

interventions that are based on social and behavioral science theories are more

effective than those lacking a theoretical base. This article provides an overview

of the state of the science of theory use for designing and conducting health-

promotion interventions.

Influential contemporary perspectives stress the multiple determinants and

multiple levels of determinants of health and health behavior. We describe key

types of theory and selected often-used theories and their key concepts,

including the health belief model, the trans-theoretical model, social cognitive

theory, and the ecological model.

13
Health promotion perceptions among community pharmacists in Nigeria the

Objective is to explore the attitudes of Nigerian community pharmacists

towards health promotion, to determine the importance pharmacists attach to

health promotion behaviours and their perceived involvement in promoting

them among their clients. They conducted a cross-sectional survey of

community pharmacists in two Nigerian cities. Attitudes toward health

promotion were assessed using a 24-item instrument. The importance

pharmacists attach to healthy behaviours as well as their perceived involvement

was assessed using a 23-item standard instrument. Interval data on

questionnaire items were gathered on a Likert-type scale, and the demographic

characteristics of the respondents were also profiled. Principal factor analysis

employed Varimax rotation with Kaiser normalization. Associations between

demographic profile and responses were evaluated using Student's test and one-

way ANOVA. Results shows about 84% of the respondents indicated a

favourable attitude towards health promotion. Nearly all the respondents (98%)

were interested in health promotion services, and 94% indicated willingness to

devote extra time to talk to patients. A majority (93%) reported willingness to

retrain on health promotion. Lack of health promotion policy for pharmacists,

and negative attitude towards the utilization of pharmacy technicians were

potential barriers.

14
 Public health promotion in Nigeria: a sociological viewpoint

After identifying four main social problem-areas pertaining to ill-health in

Nigeria presents as a guideline for tackling some of these problem-areas a

thought scheme demonstrating the linkages between levels of health

responsibilities and the corresponding methods of public health promotion

adoptable at each level. The differentiated levels of health responsibilities are:

the individual, the family, the community, the Federal and State Ministries of

Health. Perdiguero, E. (2001)

Important of Health Promotion

i. Health promotion improves the health status of individuals, families,

communities, states, and the nation.

ii. Health promotion enhances the quality of life for all people.

iii. Health promotion reduces premature deaths.

iv. By focusing on prevention, health promotion reduces the costs (both financial

and human) that individuals, employers, families, insurance companies,

medical facilities, communities, the state and the nation would spend on

medical treatment.

Where are Public Health Educators Employed?

15
In schools health educators teach health as a subject and promote and

implement Coordinated School Health Programs, including health services,

student, staff and parent health education, and promote healthy school

environments and school-community partnerships. At the school district level

they develop education methods and materials; coordinate, promote, and

evaluate programs; and write funding proposals. Perdiguero, E. (2001)

Working on a college/university campus, health educators are part of a team

working to create an environment in which students feel empowered to make

healthy choices and create a caring community. They identify needs; advocate

and do community organizing; teach whole courses or individual classes;

develop mass media campaigns; and train peer educators, counselors, and/or

advocates. They address issues related to disease prevention; consumer,

environmental, emotional, sexual health; first aid, safety and disaster

preparedness; substance abuse prevention; human growth and development; and

nutrition and eating issues. They may manage grants and conduct research. In

companies, health educators perform or coordinate employee counseling as well

as education services, employee health risk appraisals, and health screenings.

They design, promote, lead and/or evaluate programs about weight control,

hypertension, nutrition, substance abuse prevention, physical fitness, stress

management and smoking cessation; develop educational materials; and write

grants for money to support these projects. Perdiguero, E. (2001)

16
They help companies meet occupational health and safety regulations, work

with the media, and identify community health resources for employees. In

health care settings health educators educate patients about medical procedures,

operations, services and therapeutic regimens, create activities and incentives to

encourage use of services by high risk patients; conduct staff training and

consult with other health care providers about behavioral, cultural or social

barriers to health; promote self-care; develop activities to improve patient

participation on clinical processes; educate individuals to protect, promote or

maintain their health and reduce risky behaviors; make appropriate community-

based referrals, and write grants. In community organizations and government

agencies health educators help a community identify its needs, draw upon its

problem-solving abilities and mobilize its resources to develop, promote,

implement and evaluate strategies to improve its own health status. Health

educators do community organizing and outreach, grant writing, coalition

building, advocacy and develop, produce, and evaluate mass media health

campaigns.

Where Can One Receive Health Promotion or Health Education Training?

Some people specialize in health education and seek training and certification as

health education specialists. Others perform selected health education functions

as part of what they consider their primary responsibility (medical treatment,

nursing, social work, physical therapy, oral hygiene, etc.). Lay workers learn on

17
the job to do specific, limited educational tasks to encourage healthy behavior.

Para-professionals and health professionals from other disciplines are not

familiar with the specialized body of health education knowledge, skills,

theories, and research, nor is it their primary interest or professional

development focus. This will limit their effectiveness with clients and

communities, and their cost- effectiveness. Karen Glanz and Donald B (2010)

Conclusion

There is an indication that the Health promotion perceptions among community

pharmacists in Nigeria Nigerian community pharmacists in this survey

perceived an extended role in health promotion, especially medication-related

activities. This is consistent with the philosophy of primary healthcare and

pharmaceutical care. However, Reviews of research on changing a variety of

health behaviors have shown that interventions based on theory or theoretical

constructs are more effective than are those not using theory. Furthermore, the

mechanisms that explain the larger effects have not been studied. The most

often used theories of health behavior are social cognitive theory (SCT), the

trans-theoretical model (TTM)/stages of change, the health belief model

(HBM), and the theory of planned behavior (TPB).

The most often mentioned theoretical model that has not been fully applied in

research and practice is the social ecological model. There are many needs to

better articulate, apply, and evaluate this important and promising model.

18
Health-promotion and public health researchers and practitioners should both

question and improve how thoroughly we use theory, how we turn theories into

interventions, how we test theories, and what conclusions we draw from

research. Health-promotion programs that address significant public health

problems including health disparities should complement individually oriented

intervention models with strategies and models to develop healthier policies,

systems, and environments.

19
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