The Challenge of the ‘ Art and Science ’ of Health Promotion

Health promotion has a key role to play in preventing disease and promoting healthy lifestyles. Health promotion work is part science and part art. The science emerges from research and theory and the art emerges from our professional intuition and experience. The goal is to apply the science to achieve the best health promotion outcomes. However, an application of the theory, models and even the evidence, does not guarantee a desired outcome. To achieve this is an art and something that is often missing in practice. An understanding of how best to apply the ‘art and science’ of health promotion requires an appreciation that it is not only about being scientifically right but also about being real. The challenge for health promoters is to understand how they can use their judgement to best apply the available science to deliver successful approaches.

The role of health promotion has remained largely consistent since its inception in the Ottawa Charter in 1986 as 'the process of enabling people to increase control over, and to improve their health' [1].What has changed are new opportunities for communication created by technological advances, and a shift in professional thinking towards the need to actively engage with communities by being more sensitive to the situational context.Health promotion work is part science and part art.The science emerges from research, evidence and new knowledge, and the art emerges from our professional judgment, intuition and previous experiences [2].
The 'science' of health promotion comes from theories and models, from research and new knowledge that have been developed into a broad range of approaches, tools and strategies designed to deliver interventions, projects and programmes.Health promotion theory originates from the social and behavioural sciences drawing on knowledge from psychology, sociology, programme management, marketing, community development and the political sciences.The evidence to support health promotion theory is not comprehensive, especially in the theory of intervention and there are gaps about the effectiveness of what works.There are a range of health-related issues, target groups, settings and contexts, and this can necessitate the use of more than one theory or model.Practitioners are also constrained by time, finances and by a clear understanding of what can work in a particular programme [3].Most theories and models are not used in practice, but a few can provide a structured approach to plan and implement health promotion programmes.
Crucially, an understanding of how best to apply the 'art and science' of health promotion requires an appreciation that any successful approach is not only about being scientifically right but also about being real.The 'art and science' is an understanding of how best to apply the theory and evidence in a particular context to achieve a particular outcome.

Applying the 'Art and Science' of Health Promotion
In our professional desire to understand the causes of the causes of poor health, we may have underestimated the effort required to understand how best to apply the 'art and science' of health promotion.This has been manifested in our professional inability, for example, to engage at a practical level with the 'causes of the causes' of the Social Determinants of Health, and now with the new challenge of finding a meaningful role in achieving the Sustainable Development Goals.
Applying a health promotion approach in one context might be successful, but in another context, it could fail.An application of the theory does not guarantee a change in behaviour, an increase in knowledge, or a gain in control over people's health and lives.The art of health promotion is about knowing when and how to use a specific approach to achieve the desired outcome.In the past, when health promotion had failed to change behaviour, we tended to 'blame the victim'; for example, for drinking too much alcohol and eating too much high-fat and sugary foods, for continuing to smoke, even though people knew it was harmful, and for being physically inactive.This led to feelings of disempowerment and of mistrust between health promoters and the public.This situation was further exacerbated by the changing health advice given by health promoters, for example, regarding alcohol consumption and vaccination.Health promotion relied heavily on theories that explained individual health behaviour change, and on the use of health education, the development of personal skills, and on influencing perceived norms.
Applying the 'art and science' of health promotion is difficult, because there is a broad range of concepts, many of which have not been fully tested.Health promotion models tend to seek to represent simplified versions of reality that do not truly reflect the complexities of people's lives and of social behaviour [4].Over time, there has been a shift in professional thinking away from using pre-packaged approaches that focus on individual behavioural change, and towards greater community engagement.Theories on collective action and capacity building, and models for organisational change, inter-sectoral action and the development of healthy public policy now provide opportunities for community-based intervention, empowerment and addressing inequalities.The lessons learnt from a range of programmes have raised our professional awareness for more balanced top-down and bottom-up approaches that increase the chances of effectiveness and sustainability.
Applying the 'art and science' of health promotion relies on an evidence-based approach.The challenges of this are the fragmented nature of what we know works, the poor availability of new knowledge and a lack of competence in interpreting and transferring what is available into practice.Health promotion approaches fail when they rely too much on the science, which is often weak or non-existent, and do not appreciate the value of professional judgment.This is a situation that can be improved by presenting evidence-based findings that are contextually relevant and as programme recommendations.However, to achieve this, researchers must first have an understanding of the practical context, so that they can identify what works or does not work in a range of settings; something that is often missing in the literature [5].

Future Challenges to Health Promotion
To address the challenges of the 'art and science' in the future we must be honest with ourselves as health promotion professionals.The evidence for what works in health promotion is weak, and practitioners often lack the experience and know how to apply the many theories, models and approaches that they have at their disposal, for the different contexts in which they work.
The call to develop the 'science' of health promotion as acceptable standards for an evidence-based approach has led to the start of a movement to address this issue.International agencies have taken on the challenge of identifying what works and what does not work in health promotion and to advocate for more research where there are gaps in the evidence [6].It will take time to make the science more reliable and to develop acceptable standards of practice, but the profession is well aware of the need to move forward using stronger evidence-based approaches.
The second challenge refers to giving practitioners a better sense of judgement about what evidence, theories or models to apply in a particular context.The 'art' of health promotion is subjective, because a decision is based on the judgment of the practitioner, who uses their past experiences, depending on any particular set of circumstances.The 'art' of health promotion will also take time to develop, but it is possible to enable practitioners to make better judgments about how to achieve a successful outcome.The foundations of health promotion come from innovative thinkers such as Saul Alinsky [7] and Aaron Antonovsky [8], and led to approaches with a focus, for example, on the relationship between health, stress, and coping.This type of thinking can help future curriculum development and training, with an emphasis on exposure to community work, and on case-study experiences, to offer more of an insight into practice.We need more innovative ideas about how to improve both the confidence and the broad range of skills that make up professional competence in applying the 'art and science' of health promoters.
The 'art and science' of health promotion is not an either/or situation; it is about both the application of good judgment and the availability of relevant knowledge.Good judgement requires more and varied experience, and the relevant knowledge requires applied research that can be directly transferred into practice.
A key future challenge for health promotion is to develop a cadre of professionals that are able to bridge the gap between theory and practice, and who are trained in the application of the 'art and science' in a range of contexts, including in fragile populations, and in using new communication technologies.