How health promotion prevents itself from tackling health inequalities. A critical analysis of Dutch health promotion's paradigm through its handbooks (1995–2022)

Abstract

Health inequalities are a central concern within the field of health promotion. Yet, for over four decades, research has consistently shown that socioeconomic health inequalities in Western Europe persist and, on some measures, even have widened. Explanations are typically sought in the behaviours or personal characteristics of ‘unhealthy populations’ or in neoliberal policies. However, the role that health promotion itself, through its central theories, methods and assumptions, plays in the persistence of health inequalities is rarely considered. This study addresses this gap: it explores how health promotion's paradigm informs professionals to reduce health inequalities. Since paradigms are conveyed through handbooks, we conducted a qualitative content analysis of multiple editions of three key handbooks used in Dutch graduate health promotion education, published between 1995 and 2022. Using Science and Technology Studies's notion ‘paradigm’ and the theoretical lens of formal, hidden, and null curricula from Critical Education Studies, we show that Dutch health promotion professionals have been socialised into a remarkably consistent paradigm for three decades. This paradigm, which draws heavily from socio-cognitive psychological models, teaches professionals to prioritise individual behaviour change and not to challenge sociopolitical actors whose actions contribute to ill-health. Justifications remain limited to considerations such as convenience, ease and cost-effectiveness. The handbooks that convey this paradigm continue to be used in Dutch graduate education, training the health promotion professionals of the future. We argue that, at least in the Netherlands, the prevailing paradigm of health promotion is a significant, yet overlooked, factor in the persistence of health inequalities.