Opportunities for the practice of health promotion: the assets model and NICE guidelines


We understand health promotion as the social and political process through which people and communities are enabled to take control over and improve their own health. Ever since the publication of the Ottawa Charter in 1986 we have tried to cover the difficult and innovative distance between theoretical definitions and the practical implementation of health promotion: to implement processes of change so that people are able to improve control over factors determining their health.

This processes share a starting position: the definition of health, of determining factors and the identification of every-day life issues concerning people or communities involved in a health promotion program or intervention. We know that health is a complex concept including physical, psychological and social aspects; which considers both objective elements, for an appropriate functioning for certain activities, and a subjective impression of welfare, regarding the capacity of people to face the environment's challenges to live and develop their existing potential.

Although this may be like that from a theoretical point of view, in practice health promotion is excessively influenced by a biomedical approach and focused on behavior and lifestyle changes to the detriment of other health determinants such as community and social networks, life and working conditions and socioeconomic and cultural circumstances. Changing certain environments such as towns, neighborhoods or correctional facilities to enable healthy choices; incorporating health in all policies to improve living conditions, intersectoral work, participation and creation of community networks in favor of health empowerment and the re-orientation of our healthcare services towards this kind of interventions seem not to be in the agenda of health promotion. This "empty" agenda of interventions on social determinants of health totally contradicts evidence and WHO indications1.

In spite of all this, we believe that we are in a moment "full" of opportunities to go from theory to practice, and from practice focused on behaviors and lifestyles to practice focused on social determinants of health, opportunities that we will now discuss.

General Act 33/2011 as of October 4th, on Public Health provides today's policy framework to enhance the practice of health promotion in the Spanish territory by considering: the modification of social, working, environmental and economic conditions to improve their impact on health; the implementation of interventions from the environments and through the creation of networks, the introduction of quality criteria and the acknowledgement of good practices, the participation of citizens both directly and through social organizations, programs or interventions. The Health Promotion and Disease Prevention Strategy of the National Health System is a good starting point to update and strengthen the practice of health promotion in several proximity environments especially locally2-3. Yet, how can we benefit from the opportunity of available policy and strategic action frameworks? A key point would be systematizing the practice of health promotion from theories and intervention models which prove to be effective based on contrasted experience and evidence.

In recent years, the approach based on positive health and the asset model has been established as a revitalization and change tool for health promotion4-5. This approach allows us to go beyond behavioral aspects and to systematize a more coherent practice in line with the inspiring principles of health promotion. The assets model is derived from the salutogenic theory and is based on the creation of assets maps to implement health generation actions based on the connection and revitalization of identified assets and eventually, to evaluate these actions by means of indicators of change.

There are different types of assets in a territory (people, groups, associations, services, institutions, physical spaces and facilities, local economy elements and cultural expressions) that must be identified by professionals and citizens through participation processes which should result in an assets map within the intervention. These assets are related with health determinants: they are interconnected and entail action proposals. The process enables the design of coordinated synergic simultaneous actions on different types of determinants to improve the possibilities of success and change. We currently have different methods to create assets maps in different environments, including correctional facilities6, but we need to develop and evaluate projects based on the model to prove their efficacy in comparison with other approaches solely based on facing needs or issues.

Another key aspect to revitalize health promotion is to incorporate the perspective of evidence-based practice. In England, the National Institute for Health and Care Excellence (NICE) has extensive experience in the development of evidence-based guidelines for both healthcare and public health settings7. NICE is an independent organization created in 1999 aimed at providing national guidance for an improved clinical practice in the National Health System. In 2005 they started publishing public health guidelines and in 2013 they included social care issues. Before 2005, "C" stood for Clinical excellence, but now it makes reference to excellence in care or comprehensive healthcare. Thus, NICE's main roles are the following:

1) To identify good clinical public health and social action practices by the determination of the best available evidence.

2) To reduce uncertainty among professionals and the general public, as well as among service users.

3) To reduce variation of available services and quality of practice and care provided.

NICE public health guidelines include recommendations for local authorities and other stakeholders aimed at health promotion and disease prevention. Currently, of 253 guidelines, NICE offers 60 on public health which you can freely access through their website http://www.nice.org.uk/guidance/published?type=ph.These guidelines are classified according to whether they issue: Conditions and diseases, Health protection; Lifestyles and wellbeing; Population groups; Service delivery; Organization and stafffing or Settings. By reviewing guidelines and according to health promotion criteria we could consider that NICE currently has nineteen guidelines on key aspects of the practice of health promotion (see Table1). NICE also provides guidelines on other essential issues for our national health system such as chronic diseases, mental health, obesity and eating. The recommendations can be used as a starting point for the design of new interventions regarding health promotion or the evaluation or update of running programs needing evidence-based revision. In short, putting into practice what we know that works and stop doing what doesn't.

In Spain, prison health has been determined by the innovation and provision of input ti the practice of health promotion that have transcended the community such as, for example, peer learning and group workshops on HIV or harm reduction measures regarding substance abuse8-9 or the promotion of mental health10-11. In this climate of health promotion revitalization, prisons should not and must not fall behind. The development of a health assets model and the implementation of properly adapted NICE guidelines are two possible innovations that could enable the systematization of evidence-based practice of health promotion. If we now how to do it there is nothing against its implementation. It is therefore necessary to systematize and evaluate actions on health promotion through quality standards12 and ultimately, by developing good practices that can be shared.


Joan J. Paredes-Carbonell
General Sub-directorate for Health Promotion and Prevention
(General Directorate of Public Health - Generalitat Valenciana)



1. WHO. Social determinants of health: the solid facts. Madrid: Ministerio de Sanidad y Consumo; 2006

2. Ministerio de Sanidad, Servicios Sociales e Igualdad. National Strategy on Health Promotion and Disease Prevention of the National Health System. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad; 2013.

3. Ministerio de Sanidad, Servicios Sociales e Igualdad. Guía para la implementación local de la Estrategia de Promoción de la Salud y Prevención en el SNS. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad; 2015.

4. Morgan A, Ziglio E. Revitalising the evidence base for public health; an assets model. Promot Educ. 2007; 14: 17-22.

5. Morgan A, Hernán M. Promoción de la salud y del bienestar a través del modelo de activos. Rev. esp. sanid. penit [Internet]. 2013 Feb [citado 2016 Ene 16]; 15(3): 78-86. Disponible en: http://scielo. isciii.es/scielo.php?script=sci_arttext&pid=S1575 06202013000300001&lng=es.

6. Vera-Remartínez EJ, Paredes-Carbonell JJ, Aviñó D, Jiménez-Pérez M, Araujo-Pérez R, AgullóCantos JM, et al. Sentido de coherencia y mapa de activos para la salud en jóvenes presos de la Comunitat Valenciana (España). Global Health Promotion. Forthcoming 2015.

7. Morgan A. The benefits and challenges of evidence based public health: the experience of the National Institute for Health and Care Excellence. Gac Sanit. 2013; 27(4): 287.

8. Aviñó A, Bustamante R, González-Aracil J, González-Rubio J, Paredes-Carbonell JJ, Pitarch MC. Programa Lluna: una guía de intervención para la promoción de la salud en el medio penitenciario. Rev Esp Sanid Penit. 1999; 1: 88-92.

9. Arenas, C. (Coord.). Guía de Mediación en Salud en el Medio Penitenciario. Educación para la salud, reducción de daños y apoyo entre iguales en el medio penitenciario. Madrid: Ministerio del Interior. Secretaria General de Instituciones Penitenciarias; [ca. 2010].

10. Equip Vincles Salut. Guía para la promoción de la salud mental en el medio penitenciario. Madrid: Ministerio del Interior. Secretaria General de Instituciones Penitenciarias; 2011.

11. Bustamante R, Paredes-Carbonell JJ, Aviñó D, J González, C Pitarch, L Martínez, JM Arroyo. Diseño participativo de una Guía para la Promoción de la Salud Mental en el Medio Penitenciario. Rev Esp Sanid Penit. 2013; 15: 44-53.

12. Granizo C, Gallego J. Criterios de Calidad en Promoción de la Salud. Zaragoza: Gobierno de Aragón; 2007.


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