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Health promotion is built on a persistent tension: should it focus on changing individual behaviors—encouraging people to eat better, exercise more, and stop smoking—or on reshaping the social, economic, and environmental conditions that make healthy choices possible? That tension has driven the evolution of six major frameworks since the mid-twentieth century, each responding to the blind spots of its predecessors while remaining in active use today.
In the 1950s, as chronic diseases like heart disease and cancer replaced infectious diseases as leading causes of death, public health turned to epidemiology to identify individual risk factors: smoking, high blood pressure, poor diet, physical inactivity. The Biomedical/Risk Factor Reduction Framework emerged from this mindset, treating health promotion as a matter of educating individuals about risks and delivering clinical interventions (screening, medication, counseling). It assumed that knowledge leads to behavior change and that population health improves when enough individuals reduce their personal risk.
This framework remains dominant in clinical preventive medicine and mass-media campaigns. Its strength is its clarity: it produces measurable targets (e.g., “reduce smoking prevalence by 10%”) and fits easily into healthcare systems. But its critics note that it blames individuals for conditions shaped by poverty, housing, and workplace stress—and that behavior-change gains often reinforce social inequalities.
By the late 1970s, the limits of purely individual-focused promotion had become visible. Two frameworks proposed different correctives.
The Empowerment and Community Participation Framework (1978) flipped the direction of authority. Rooted in the 1978 Alma Ata Declaration’s call for “primary health care” that involves communities in their own health, this framework argued that lasting change requires communities to define their own problems and solutions, not merely receive expert advice. It shifted attention from individual compliance to collective action—tenant unions organizing against lead paint, residents demanding safe parks. Empowerment coexists uneasily with the Biomedical framework because it rejects top-down expertise and prioritizes political agency over clinical outcomes.
In the same period, the Salutogenic Framework (1979), proposed by medical sociologist Aaron Antonovsky, asked a fundamentally different question: instead of “what causes disease?” (pathogenesis), it asked “what creates health?” (salutogenesis). Antonovsky argued that people with a strong “sense of coherence”—a belief that life is comprehensible, manageable, and meaningful—stay healthier even under stress. The Salutogenic Framework does not compete directly with the Biomedical model; rather, it offers a parallel lens, suggesting that health promotion should strengthen people’s resources for coping, not just remove risks. While it remained somewhat academic for decades, it has lately revived, especially in mental health and workplace well-being.
The Ottawa Charter for Health Promotion, adopted in 1986, is the most widely cited document in the field. It wove together earlier threads into a coherent agenda: health promotion “is the process of enabling people to increase control over, and to improve, their health.” The Charter listed five action areas: build healthy public policy, create supportive environments, strengthen community action, develop personal skills, and reorient health services. This explicitly broadened promotion beyond lifestyle advice to legislation, fiscal measures, and organizational change—absorbing the Empowerment framework’s community focus while also endorsing the policy advocacy that Empowerment sometimes lacked. Ottawa Charter Health Promotion became the official platform of the World Health Organization and remains the touchstone for national and international strategies.
Yet the Charter’s breadth creates tension: it calls simultaneously for individual skill-building (near the Biomedical model) and for structural change (near the Empowerment model). This has allowed different practitioners to emphasize different parts of the Charter, producing ongoing disagreements about where limited resources should go.
In the same year as the Ottawa Charter, the Socio-Ecological and Settings-Based Approach offered a practical method for implementing the Charter’s vision. It recognized that people live in multiple, interacting environments—schools, workplaces, neighborhoods, cities—and that health promotion must act at all levels simultaneously. The settings approach created iconic programs: Health Promoting Schools, Healthy Cities, Health Promoting Hospitals. These programs design interventions that change the physical, social, and organizational features of a setting while involving its members in decision-making.
This framework narrows the Ottawa Charter’s broad vision into a manageable unit of action. It coexists comfortably with the Empowerment framework—both emphasize participation—but it also incorporates the Biomedical framework’s concern for measurable outcomes (e.g., reduced injuries in a hospital). The settings approach has become arguably the most influential operational model in health promotion today.
The Health Literacy Framework, which emerged around 1990, focuses on the skills people need to navigate an increasingly complex health system. Early health literacy efforts measured basic reading ability (e.g., understanding a prescription label). Over time, the concept expanded to include critical health literacy: the ability to analyze information, question authority, and advocate for oneself. This placed it close to the Empowerment framework, since both aim to give individuals and communities control over their health decisions.
Yet the Health Literacy Framework has also narrowed the field in a particular way: by concentrating on cognitive and navigational skills, it risks returning to a form of individual-level intervention, especially in its popular “health literacy training” programs. Its relationship with the Socio-Ecological Approach is thus ambivalent—health literacy is often treated as a personal asset, while the settings approach insists that the environment, not just the individual, must be the target of change.
Today, no single framework dominates health promotion. The leading frameworks—Ottawa Charter Health Promotion, Socio-Ecological and Settings-Based Approach, and Empowerment and Community Participation—agree on several core principles: health promotion must address structural determinants, involve communities, and work across multiple levels. There is broad consensus that the Biomedical/Risk Factor Reduction model, by itself, is insufficient.
But deep disagreements remain. The most persistent is about resources. The Biomedical framework commands the most funding and institutional support (healthcare systems, insurance programs), so its individual-level interventions (screening, counseling) continue to dominate practice. The Socio-Ecological Approach calls for cross-sectoral action—housing, education, transport—but these lie outside health budgets, so settings-based projects often struggle to scale. Empowerment practitioners argue that even well-designed settings programs can descend into token participation unless they cede genuine power to communities. Meanwhile, the Health Literacy Framework has become a pragmatic compromise: it fits within clinical settings and policy documents, but its critics claim it overemphasizes skill deficits and underemphasizes the structural barriers that make “good choices” hard.
The Salutogenic Framework has found a niche in quality-of-life research and positive psychology, complementing but not replacing the others. The Ottawa Charter remains the official consensus document, but its very comprehensiveness allows each stakeholder to pick the parts that suit them.
Thus the tension that opened the field—individual vs. structural change—is not resolved. It is sustained as a productive disagreement, with each framework clarifying what is at stake. The challenge for students and practitioners today is not to pick one true framework, but to understand what each lets us see, what it hides, and how they might be combined without contradiction.