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Global Health Promotion 1757-9759; Vol 18(2): 54–57; 404770 Copyright © The Author(s) 2011, Reprints and permissions:
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Commentary
Health promotion as a behavioural challenge: are we
missing attitudes?
Efharis Panagopoulou1, Anthony Montgomery2 and Alexis Benos1
Abstract: Despite the considerable financial and organizational resources of health promotion cam-
paigns, their effectiveness in tackling current health problems is limited. In the following commen-
tary, we argue that health promotion is best understood as a behavioural challenge. Behaviour can
be understood in terms of three aspects: knowledge, skills and attitudes. While knowledge and skills
have received adequate attention, the attitudinal approach has been significantly underutilized. To
this end, we have used the examples of prevention of H1N1 transmission, hand washing in hospitals
and prevention of cervical cancer to elucidate our points. We also provide recommendations of how
the attitudinal approach can enhance the effectiveness of health promotion interventions. (Global
Health Promotion, 2011; 18(2): 54–57)
Keywords: health behaviour, health promotion
Introduction
Despite the plethora of existing health promotion
interventions, their effectiveness has yet to be
enhanced in order to successfully address current
public health problems across Europe. One of the
factors undermining the effectiveness of health pro-
motion campaigns concerns the fragmentation of
public health problems, which are treated as inde-
pendent issues and dealt with by separate agencies.
The need for agencies to work together in order to
promote a holistic approach to health promotion
rather than issue-oriented interventions has been
noted (1,2). Within such a framework, public health
issues are best understood as behavioural problems.
Behaviour, in terms of health promotion, can be
understood in terms of three aspects: knowledge,
skills and attitudes (see Figure 1). Unfortunately,
while knowledge and skills have received adequate
attention, attitudes have not. In the following com-
mentary, we will highlight how the focus on knowl-
edge and skills and the lack of focus on attitudinal
change means that behavioural approaches to
health promotion are not being fully realized. To
elucidate our arguments, we have chosen three sig-
nificant health promotion issues to review: preven-
tion of H1N1 transmission, hand washing in
hospitals and prevention of cervical cancer.
However, prior to reviewing them it is appropriate
to clarify what we mean exactly by attitudes.
Attitudes
An attitude is a psychological tendency that is for-
mulated by evaluating people, groups, situations,
objects, activities and intangible ideas, in terms of
their favourable and unfavourable qualities (3).
Attitudes towards health behaviours are influenced
by personal, family, organizational and community-
related factors. At a practical level, we can define
attitude via its constituent parts: perceived vulner-
ability, intention, outcome expectancy, perceived
behavioural control and subjective norm. Perceived
susceptibility refers to a person’s perception of risk
1. Correspondence to: Efharis Panagopoulou, Medical School, Aristotle University, Thessaloniki, Greece. Email:
Efharis@the.forthnet.gr
2. Department of Economic and Social Sciences, University of Macedonia, Thessaloniki, Greece.
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E. Panagopoulou et al. 55
IUHPE – Global Health Promotion Vol. 18, No. 2 2011
and the associated consequences; intention refers to
a person’s readiness to carry out a target behaviour;
outcome expectancy refers to a person’s beliefs
about the benefits and costs of carrying out a target
behaviour; perceived behavioural control refers to
the degree to which a person believes that the target
behaviour is under their control; and subjective
norm refers to how the opinions of relevant others
influence the person’s willingness to carry out the
target behaviour. Typically, these components of
attitudes have been applied successfully by health
psychologists to change behaviour in relatively
small groups of patients (4). However, these prin-
ciples have not been fully exploited by health
promotion campaigns.
Prevention of H1N1 transmission
Several studies have shown that the uptake of
vaccination against A/H1N1 has been very much
dependent on people’s perceptions about its efficacy,
safety and side effects (5). The perceived risks and
seriousness of the disease, opinions on the govern-
ment and healthcare systems, have influenced the
public’s compliance with antiviral prophylaxis (6).
In a recent Australian survey concerning H1N1
virus (7) a third (38%) of respondents ranked their
risk of catching influenza during a pandemic as low.
In addition, only a third (33%) reported that a pan-
demic influenza would affect their health ‘very seri-
ously’, and just over half of the respondents (58%)
believed the pandemic would be over within a year.
In a study conducted in Greece in August 2009,
53% of people with chronic diseases indicated nega-
tive intention towards vaccination. Factors associ-
ated with the intention to decline was the belief that
the vaccine was not safe, and low perceived risk
associated with influenza (8).
However, despite the evidence about the role of
attitudes in complying with preventive measures
against H1N1 transmission, health promotion cam-
paigns have not taken into account the attitudinal
barriers to the pandemic vaccine. Understanding the
way that the public processes health messages is
therefore a prerequisite to successfully prepare
against a flu pandemic, such as the one caused by
the H1N1 virus.
Hand washing in hospitals
Despite the fact that hand washing has been inten-
sively promoted as the most important means of pre-
venting in-hospital infections, compliance with hand
hygiene practices among health professionals is poor
(9). This raises questions about effectiveness and sus-
tainability of interventions intended to enhance
hand-washing behaviour. The majority of inter-
ventions have focused on providing information
about hand washing or teaching health professionals
how to wash their hands, and have ignored the
impact of attitudes on hand-washing behaviour. For
example, one could imagine that medical residents
Health
promotion
Knowledge
e.g. hand washing
helps to reduce in-
hospital infections
Skills
e.g. I have been taught
how to wash my hands
properly
Attitudes
e.g. Senior staff don’t always
wash their hands, therefore it is
not as crucial as they say
Figure 1. Health promotion as a behavioural challenge.
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Commentary
56
IUHPE – Global Health Promotion Vol. 18, No. 2 2011
have all the skills and knowledge required to adhere
to hand washing; however, we can easily understand
why they do not when we consider that their non-
compliant senior colleagues and teachers may be
influ encing their attitudes and beliefs in a more pow-
erful way. In the few studies where attitudinal factors
were taken into consideration (e.g. 10) the effective-
ness of interventions in improving hand-washing
behaviour was significantly increased.
Gould et al. (11) argue that the failure to improve
hand hygiene compliance can be attributed to the
inability to implement an otherwise well-designed
and educationally sound programme. This inability
could be overcome by addressing the attitudinal
barriers to hand washing.
Prevention of cervical cancer
The recognition of the central role of human pap-
illoma viruses (HPV) in the aetiology of cervical
cancer, and the development of vaccination for cer-
vical cancer prevention, had led to extensive media
coverage and public awareness programmes (12).
Such campaigns have been mainly focused on the
provision of information. As a result, awareness has
increased. However, recent studies have showed
that, together with an increase in knowledge about
HPV, the actual uptake of cervical screening is
falling in some groups of younger women (13,14).
The fact that HPV vaccination can adversely affect
the uptake of cervical screening highlights the dele-
terious effects of ignoring attitudinal issues. If the
public develop the misconception (attitude) that the
HPV vaccination has removed the need for screen-
ing, this can result in the belief that HPV vaccina-
tion is a sufficient means of protection against
cervical cancer, and may actually reduce attendance
for cervical screening. Several studies have shown
that parental health beliefs towards prevention have
influenced HPV vaccine uptake among adolescent
girls (15). If young women feel vulnerable to acquir-
ing cervical cancer (perceived susceptibility), and if
their parents and peers endorse that view (subjective
norm), they are more likely to accept the vaccina-
tion. Cervical screening in the post-vaccination era
would significantly benefit from a strategy that
adopted an attitudinal approach.
Conclusions and recommendations
The application of behavioural principles to
health promotion is a relatively recent phenomenon.
While the provision of knowledge and skills has
been successfully used to empower patients and
communities, the use of attitudinal technology has
still been significantly underutilized.
The dynamic of behavioural change is complex
and multifaceted. However, there is plenty of evidence
Table 1. Attitudinal components applied to prevention of H1N1 transmission, hand washing in hospitals and
prevention of cervical cancer
Prevention of H1NI
transmission
Hand washing in
hospitals
Prevention of cervical cancer
Perceived susceptibility Because of my job, it is
very likely that I will be
infected by H1N1
Because of my health
condition I am also
likely to get an infection
from a patient
Because of my age, the
possibility of getting cervical
cancer is very small
Intention I will visit the health
centre to get vaccinated
I will wash my hands
before every surgery
I will have a Pap test once a
year
Outcome expectancy Having the vaccine has
more side effects than the
disease itself
Washing my hands will
protect patients
Pap testing is more
embarrassing than the
vaccine
Perceived behavioural
control
There might not be
enough vaccines for
everybody
Washing my hands
before every surgery
requires extra time
I have enough information
about where and how to
have the vaccine
Subjective norm My colleagues have got
the vaccine
All the other staff wash
their hands regularly
My parents think that it is a
good idea to have the
vaccine
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E. Panagopoulou et al. 57
IUHPE – Global Health Promotion Vol. 18, No. 2 2011
to suggest that changing people’s attitudes will lead
to changing their behaviour (16). In terms of recom-
mendations, attitudes can be employed in two ways.
First, attitudinal components can be used to evalu-
ate unsuccessful health promotion strategies. The
attitudinal taxonomy provides an easy way for pro-
viders to evaluate to what degree a health promo-
tion strategy has not addressed the motivational
factors, intentional factors, outcome expectancies,
perceived behavioural control and subjective norms
of the target group. Table 1 provides an example of
how the attitudinal components can be applied to
the three health issues that we have discussed.
Second, future health promotion strategies will be
more effective if they adopt some of the basic prin-
ciples of attitude change:
• People will change their behaviour if they believe
that benefits from the change are more than the
losses.
• People will change their behaviour if they believe
that they are at risk of a disease, in combination
with the importance they attribute to the disease.
• People will change their behaviour if they believe
they can do it.
• People will change their behaviour if they believe
that significant others expect them to do so.
The greatest strength of the attitudinal
approach, in contrast to a knowledge or skills
one, is that it forces us to consider the ample
reasons that individuals have for not changing
their health behaviours.
References
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IUHPE – Global Health Promotion Vol. 18, No. 2 2011
la théorie et susceptible de saisir les données probantes souvent complexes, diffuses et obtuses, sur la
participation. En examinant comment les mécanismes de recherche participative et les facteurs contextuels
arbitrent et modèrent les résultats, cet examen va générer et tester des hypothèses (théories de moyenne
portée) pour conceptualiser les bénéfices de la participation, et va décrire de quelle manière et dans quelles
conditions la participation influence les résultats. (Global Health Promotion, 2011; 18(2): 45–48)
Que faut-il faire en Chine pour combler le fossé entre résolution et mise en
œuvre de la promotion de la santé ? Une réponse à l’Appel à l’action lancé par
l’OMS à Nairobi
Y. Li, M. Tao et H. Fu
Afin de répondre à l’Appel à l’action lancé par l’OMS à Nairobi, cet article présente les résultats d’une
analyse SWOT (acronyme dérivé de l’anglais et qui comprend une analyse des forces, faiblesses, opportunités
et menaces) des activités de promotion de la santé actuellement en cours en Chine, et émet des recommandations
pour mettre en pratique cet Appel à l’action en tenant compte de la réalité et de la culture chinoises.
La Chine, comme tous les pays, est confrontée à la menace de pandémies mondiales (SRAS, H1N1 et
autres), à la croissance inexorable des maladies non-transmissibles, à la récession mondiale, au changement
climatique, à des crises alimentaires et au terrorisme. Pour atteindre donc à la fois un niveau de bonne santé
et plus d’équité en santé, il faut envisager une approche globale qui donne aux individus et aux communautés
des capacités et des moyens, qui favorise le leadership en santé publique et facilite l’action intersectorielle
pour développer des politiques publiques favorables à la santé et créer des systèmes de santé durables. Ces
éléments constituent les fondements de la promotion de la santé.
Cependant, comment combler le fossé qui sépare la théorie de la pratique ? La 7ème Conférence mondiale
de l’OMS pour la Promotion de la Santé qui s’est tenue à Nairobi, au Kenya, du 26 au 30 octobre 2009, a
choisi de se concentrer sur cette question. Le thème de cette conférence était Promouvoir la santé et le
développement, combler le fossé de la mise en œuvre. L’Appel à l’action de Nairobi a été lancé, appelant
l’ensemble des gouvernements et des parties prenantes à répondre de façon urgente en entreprenant des
actions s’inscrivant dans cinq sous-thèmes : le renforcement des capacités pour la promotion de la santé, le
renforcement du système de santé, les partenariats et l’action intersectorielle, le renforcement des capacités
communautaires, l’alphabétisation en santé et les comportements en matière de santé. Il s’agit d’un appel axé
sur l’action dont le point central est que les pays et régions individuellement doivent y répondre en se basant
sur leurs contextes locaux. (Global Health Promotion, 2011; 18(2): 49–53)
La promotion de la santé en termes de défi comportemental : passons-nous à
côté des attitudes ?
E. Panagopoulou, A. Montgomery et A. Benos
Malgré les ressources financières et organisationnelles considérables des campagnes de promotion de la santé,
l’efficacité dont elles font preuve pour traiter les problèmes de santé actuels est limitée. Dans le commentaire
suivant, nous soutenons que la promotion de la santé est mieux comprise en termes de défi comportemental. Le
comportement peut être compris selon trois aspects : les connaissances, les compétences et les attitudes. Si l’on a
accordé aux connaissances et aux compétences l’attention qu’il convenait, en revanche, l’approche attitudinale a
été largement sous-utilisée. Afin d’expliquer nos arguments, nous avons utilisé des exemples de prévention de la
transmission du virus H1N1, le lavage des mains en milieu hospitalier et la prévention du cancer du col de l’utérus.
Nous fournissons également des recommandations quant à la manière dont l’approche par les attitudes peut
améliorer l’efficacité des interventions de promotion de la santé. (Global Health Promotion, 2011; 18(2): 54–57)
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Resúmenes 95
IUHPE – Global Health Promotion Vol. 18, No. 2 2011
y desacertados relativos a la participación. Al analizar cómo los mecanismos de la IP y los factores contextuales
arbitran y moderan los resultados de la misma, el estudio generará y verificará hipótesis (teorías de alcance
medio) conceptualizando los beneficios de la participación y describirá la forma y las circunstancias en las
que la participación influye en los resultados. (Global Health Promotion, 2011; 18(2): 45–48)
¿ Qué deberíamos hacer en China para subsanar las deficiencias existentes en la
ejecución de la promoción de la salud ? Respuesta al Llamamiento de la OMS
en Nairobi
Y. Li, M. Tao y H. Fu
Respondiendo al Llamamiento de la OMS en la Conferencia de Nairobi, el texto expone los resultados de un
análisis DAFO (debilidades, amenazas, fortalezas y oportunidades) de las actividades de promoción de la
salud actuales en China, y formula recomendaciones para llevar a la práctica el Llamamiento de Nairobi, en
base a la cultura y la realidad chinas.
China, como todos los demás países, se enfrenta a los problemas de la amenaza de las pandemias mundiales
(SARS, H1N1 y otras), el aumento inexorable de las enfermedades no transmisibles, la recesión mundial, el
cambio climático, la crisis alimentaria y el terrorismo. Por ello, el objetivo de lograr una buena salud y
alcanzar la equidad en esta materia depende de un enfoque integral que fomente la autonomía de las personas
y de las comunidades, promueva el liderazgo para la salud pública y fomente también la acción intersectorial
para generar políticas públicas que favorezcan la salud y construyan sistemas de salud sostenibles. Estos
elementos constituyen los cimientos de la promoción de la salud.
No obstante, ¿ cómo salvar la brecha existente entre la teoría y la práctica ? En torno a esta cuestión se
celebró la 7ª Conferencia Mundial de Promoción de la Salud en Nairobi (Kenia) los días del 26 al 30 de
octubre de 2009. El tema de la conferencia fue Promover la salud y el desarrollo : Subsanar las deficiencias
en la ejecución. El Llamamiento de Nairobi para subsanar las deficiencias en la ejecución de la promoción
de la salud se concretó exhortando a todos los gobiernos y personas interesadas a que reaccionaran
urgentemente y adoptaran medidas en cinco subtemas : capacitación para la promoción de la salud,
fortalecimiento de los sistemas de salud, alianzas y acción intersectorial, empoderamiento de las comunidades,
alfabetización y conductas en materia de salud. Se trata de un llamamiento centrado en la acción y su punto
neurálgico en que las personas, los países y las regiones deben responder en función de sus respectivos
contextos locales. (Global Health Promotion, 2011; 18(2): 49–53)
La promoción de la salud como reto en el ámbito de las conductas : ¿ Prestamos
suficiente atención a la actitud ?
E. Panagopoulou, A. Montgomery y A. Benos
A pesar de la cantidad de recursos financieros y organizativos que mueven las campañas de promoción de la
salud, su eficacia a la hora de abordar los problemas de salud actuales es limitada. En el comentario siguiente,
argumentamos que la mejor forma de entender la promoción de la salud es plantearla como un reto en el
ámbito de las conductas. La conducta puede entenderse desde tres aspectos : conocimientos, habilidades y
actitudes. Si bien los conocimientos y las habilidades han recibido suficiente atención, el enfoque centrado
en la actitud ha sido infrautilizado. Con este fin, hemos empleado los ejemplos de la prevención del contagio
del H1N1, lavarse las manos en los hospitales, y la prevención de cáncer de cuello de útero para exponer
nuestros argumentos. También ofrecemos recomendaciones de cómo el enfoque que se basa en fomentar una
actitud determinada puede mejorar la eficacia de las intervenciones de promoción de la salud. (Global Health
Promotion, 2011; 18(2): 54–57)
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