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This commentary includes two primary purposes.  First, grounded in the model of values-based decision making (e.g., Bensley, 1993; Seedhouse, 2001, 2002, 2005, 2006), two influential definitions of health education and health promotion are described and critically examined.  Second, research and paradigms are positioned that substantiate an expanded form and function of health education.  The discussion of paradigms, models, and prejudices is an essential component of gaining insight into both the form and function of the field of health education (Seedhouse, 2006).  The critical review concludes that the traditional distinction between health education and health promotion has little rational or pragmatic support.  Additionally, the critical examination and contemporary research shows that modifying the perspective and traditional form of health education would enable health educators to improve the health of priority populations.
Lawrence Green and Marshall Kreuter are considered two of the most influential figures within contemporary health education and health promotion. They defined health education as “any combination of learning experiences designed to facilitate voluntary actions conducive to health.”  Health promotion, on the other hand, was defined as “the combination of educational and ecological supports for actions and conditions of living conducive to health” (Green and Kreuter, p. 27, 1999).  These definitions are normatively accepted distinctions of health education and health promotion.  David Reisman has encouraged people to “[l]ook at all the sentences which seem true and question them”   and Bertrand Russell stated that “in all affairs it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted.”  In the tradition of doubt and questioning (e.g., Hecht, 2003), the premises of volunteerism, education/schooling, and free will/determinism are examined, and alternate conclusions are positioned with regard to the distinctions between health education and health promotion.
The assumption of volunteerism
Based on Greene and Kreuter’s definitions, the distinctions between health education and health promotion depend primarily on the discriminatory power of 1) volunteerism/coercion and 2) scope of learning.  Note that health education is included as part of health promotion.  In the definition of health education, volunteerism is explicated, whereas volunteerism is implicated only in part in health promotion through the inclusion of health education.  The critical health educator must speculate on the role, place, and meaning of coercion in health education.  However, this speculative process leads to very different processes and outcomes depending on the path a health educator follows.
The following four statements are non-exhaustive two-layered examples of health education actions.  The purpose of these examples is to show the functional scope of health education as well as the diversity of health education approaches in theory and practice.  1) Health educators have advocated for stakeholders to voluntarily enact changes that predispose, enable, or reinforce voluntary changes among other people; 2) Health educators have coerced stakeholders to enact changes that predispose, enable, or reinforce voluntary changes among other people; 3) Health educators have advocated for stakeholders to voluntarily enact changes that predispose, enable, or reinforce coercive changes among other people; or 4) Health educators have coerced stakeholders to enact changes that predispose, enable, or reinforce coercive changes among other people.  The first example displays health education from the classic educational model (Tones and Tilford, 2001).  Health educators subscribing to the second example are those who follow social action figures, such as Saul Alinsky and Paolo Freire, who attempted to redistribute power within society (e.g., Alinsky, 1989; Freire, 1993, 2001; Rothman, Erlich, and Tropman, 1995).  The enactment of the third example can be found in public health tobacco smoking prohibition campaigns. The fourth example can be found in multiple United States civil rights movements in which policy makers were forced to pass laws that enforced greater equality within the United States.  All of these examples stand as legitimate forms and functions of health education and, thereby, weakens the distinction of volunteerism.
Upon reflection on these four examples of health education, if health educators assume that the necessity of complete volunteerism is untrue, then the health promotion and health education divide decreases due to the weaknesses of the premise of volunteerism.  Additionally, from the perspective of principlism (Childress, Meslin, and Shapiro, 2005), health education’s sole focus on volunteerism neglects other standard principles of research and practice such as beneficence and justice.  In practice, health educators apply models and theories that do not require the full understanding or acceptance of the action (e.g., awareness raising strategies of the Transtheoretical Model; health communications campaigns; policy advocacy).  Given the weakness of the volunteerism distinction, the primary difference between health education and health promotion would be found in the inclusion of social environment supports in the definition of health promotion; another unnecessary and under-supported premise.
The assumption of education and schooling
In the interpretation of the definition of health education, the term education should not be misunderstood to mean schooling.  Education is superordinate to schooling and therefore it is possible that schooling has little to no influence on a person’s education.  Schooling is simply one structured form of education.  As Mark Twain wrote “I have never let my schooling interfere with my education.”  With a broad view education in which the acts of imparting or acquiring knowledge via any learning method, the definitions of health education and health promotion become semantically the same, though syntactically different.  Since health educators can use any learning method, they can use alterations of physical or social environments to support learning.  Moreover, by not including social or physical environmental changes, health educators inevitably fall into the trap of victim blaming (Seedhouse, 2006; Tones and Tilford, 2001).  The definition of health education therefore does not preclude health educators from intentionally tailoring any internal (e.g., an individual’s physiology) or external environment (e.g., physical or social environment) to bring about learning experiences. The functional discriminatory weaknesses of volunteerism and education as well as the ethical interest to prevent victim blaming and embrace broad principles of research/practice shows that the typical discrimination of health and health promotion has weak foundation.   Health educators must, however, directly address issues of free will and determinism in defining health education in order to develop a clearer perspective of the form and function of health education.
The assumption of free will and determinism
Given health education’s interest in behavioral health determinants and outcomes and free will’s association with volunteerism, the issues of free will and determinism must receive additional attention and explication in the field of health education.  Hard determinism means that all present events are caused by past internal and external natural environments in the context of current natural environments and thereby negates the agency of free will and alters traditional perspectives of responsibility and freedom.  Free will positions that people have the ability to make choices that transcend natural antecedents and environments.  Libertarians completely negate determinism and express that free will is the only explanation for behavior.  Compatibilists positions that free will and determinism can coexist.  With regard to free will (compatibilism or incompatibilism) and determinism (determinism or indeterminism), there are four general philosophies under which a health educator could be categorized: hard determinist, libertarian, compatibilist (soft determinist), and blind random chance theorists (Pink, 2004; and the Stanford Encyclopedia of Philosophy, Metaphysics Research Lab, 2007).
Based on parsimony and health education in practice/theory, health education typically utilizes naturally deterministic explanations and avoids directly addressing the free will problem.  Libertarianism directly opposes the philosophies of hard or soft determinism.  Libertarian health educators would assume that nothing is naturally causally determined and that all human actions and inactions are freely chosen regardless of natural antecedents or current environments.  These health educators would be labeled victim blamers.  Compatibilists position that both free will and determinism influence behavior and therefore a person has the freedom to choose sometimes but is causally determined at other times.  The compatibilist philosophy also suffers from the potential for victim blaming but, more importantly, the possibility of arbitrary attributions—how does one decide when a behavior is freely chosen or causally determined?  How should a health educator distinguish acts of free will as opposed to manipulations of determinism, especially considering that free will is an amorphous and immeasurable construct?  The health educators of random chance believe that neither free will nor determinism exist nor influence behavior.  As a result, people are neither a reflection of nor an influence on their environments, and life is nothing more than independent periods of happenstance.  Health education theories certainly oppose purely libertarian and random chance philosophies.  However, the theoretical position of health education on hard versus soft determinism is less clear.
Based on fields of study (i.e., medicine, psychology, and sociology) that health promotion and health education have used to develop theoretical foundation, the libertarian appears unsupported.  For example, in the past, some psychologists believed in dualism, which meant that the mind and body were separate entities thereby allowing for a larger role of free will (Hunt, 1993; Wertheimer, 1987).  Contemporary psychological research, however, discounts the mind-body distinction.  Primarily, a person’s natural environment both internally and externally determines behavior (e.g., social cognitive theory and the ecological model), and free will is simply a psychological epiphenomenon (Wegner, 2002, 2004, 2008).  Health educators should therefore reject free will dominance models and follow a naturally causally deterministic framework.  Contemporary research necessitates the inclusion of external social and behavioral factors as well as internal factors (e.g., Bensen, 1997; Kawachi, Subramanian, and Kim, 2008; Levy & Sidel, 2006; Marmot & Wilkinson, 2005, Raphael, 2004; Scales and Leffert, 1999).
Prejudice in theory and practice
Health educators have recognized the importance and utility of the ecological model of health promotion for 20 years (McLeroy, Bibeau, Steckler, and Glanz, 1988), and the PRECEDE-PROCEED planning and evaluation model has included individual and environmental factors for over 15 years (Green and Kreuter, 1991).  Although internal and external influences on health have been theoretically recognized by health educators for many years, the most widely used models in health education have historically remained intrapersonal (e.g., Health Belief Model, Theory of Planned Behavior, and Transtheoretical Model) or interpersonal models and constructs (social cognitive theory).   Health education includes a paradigmatic prejudice toward focusing primarily on individual or dispositional factors and secondarily on situational or environmental factors (Crosby, Kegler, and DiClemente, 2002; Glanz, Rimer, and Lewis, 1997/2002; Noar and Zimmerman, 2005; Redding, Rossi, Rossi, Velicer, and Prochaska, 2000).    Additional research has shown that 1) health educators most preferred the philosophy of individual behavior change and least preferred social change in practice, and 2) academics were significantly less interested in social change and more interested in behavior change than practitioners (Welle, Russell, and Kittleson, 1995).
As further evidence of the historical prejudice of health educators to focus on intrapersonal factors, the philosophy of decision-making was reported to best match the beliefs of health education practitioners and academicians (Welle, Russell, and Kittleson, 1995).  Greenberg (1978) also directed health educators to focus on the decision making processes linked to arriving at a behavior instead of evaluating behavior in and of itself.  These principles were also stated in another influential article in health education—Are health educators warriors against pleasure?—in which people were to make evaluations through conscious and critical thought processes thereby resulting in better health and well-being (Russell, 2001).
More recently, Buchanan (2006) called for a new ethic of health promotion.  A broadened vision of health education was presented that suffered from a narrow view of education by advocating for a well educated populace in which people thought like those with a well rounded liberal arts education.   However, others have explained that the empowerment model is superior to both the traditional educational and medical model.  The empowerment perspective has traditionally focused more extensively on social determinants of health than the educational or medical model (Tones and Tilford, 2001).
Through the perspective of reasoned prejudice— codified, articulated, and examined biases or preferences—(Seedhouse, 2006), the prejudices of social and individual change must find a functional equilibrium in health education.  Research on social determinants of health (SDOH) and the social justice paradigm support a shift in the focus from the individual to society.  Proponents of the SDOH (Levy and Sidel, 2006; Marmot and Wilkinson, 2005, Raphael, 2004) recognize the influence and prevalence of lifestyle-focused explanations of individual’s health and quality of life but encourage extending beyond individuals and their lifestyles to the contexts in which people live—communities, cultures, and societies.
The SDOH framework sets forth influential social predictors (social gradient, income, locality, social network, social exclusion, education, employment, transportation, physical environment, health services, biology, gender, ethnicity, and culture) of health disparities that can be measured both within and between societies.  For instance, the SDOH framework helps explain the larger disparities in health in the United States compared to other countries.  SDOH refocuses the attention of health education researchers and practitioners by bringing socioeconomic factors to the forefront of program planning, implementing, and evaluating.  Canadian, British, and American research evinces the importance of extending health from individual behavior change to social change (Levy and Sidel, 2006; Marmot and Wilkinson, 2006; Raphael, 2004; Townsend, Davidson, and Whitehead, 1992; World Health Organization, 1986).  For example, sociodemographic factors predicted 56% of the variance in life expectancy among Canadians, whereas individual behaviors only added between 0% to 8% (with a median percent change between 0% and 1%) above and beyond sociodemographic factors (Shields and Tremblay, 2002).
Some health educators would use counterarguments to the proposed shift in the process of health education.  First, health educators could position that lifestyles are the most important influence on health.  For example, health educators have used information extrapolated from A new perspective on the health of Canadians: A working document (LaLonde, 1974) to justify a lifestyle model of health that extended beyond the traditional medical model (Macdonald, and Bunton, 1995).  LaLonde Report reified that: 1) lifestyle is the best predictor of disease; 2) lack of self-restraint, self-control, and responsibility result in large healthcare costs; and 3) society should not be responsible for individual lack of responsibility (Leichter, 1981).   Contemporary research supports that the lifestyle model of health has more basis in ideology than evidenced-based explanations of health determinants (Berridge and Blume, 2003; Leichter, 1981; Levy and Sidel, 2006; Raphael, 2004; Townsend, Davidson, and Whitehead, 1992; Wilkinson, 2001).  Furthermore, other historical reports, such as the as the Universal Declaration of Human Rights (Morskin, 1999) oppose LaLonde’s conclusions.  Second, health educators could claim that social change is unethical.  Given the support for determinism, lifestyle and social change both use the same processes, manipulation, to bring about change, and, as a result, justification for these manipulations should be based on health outcomes.  Social determinants of health are highly predictive of health outcomes; it would be an ethical mistake to neglect their contribution.  Third, some could position that social change is outside of the scope of health education.  The National Commission for Health Education Credentialing’s Responsibilities and Competencies (NCHEC, 2008) does not negate but supports the proposed broader vision of health education that includes social determinants.
Lifestyles (Buchanan, 2006; Glanz, Rimer, and Lewis, 1997/2002) certainly influence health, but evidence supports that an imbalanced emphasis has been placed on lifestyles.  Focusing more on social factors offers opportunities to implement more effective health education.  The field of health education must undergo a process of values clarification to improve health education alignment with contemporary evidence; especially since health education has been described as an extinct predecessor of health promotion (Macdonald and Bunton, 1995).  Evidence from SDOH and social justice shows the need for health education to revise outdated definitions and to adapt its form and function to achieve the goal of improving public health.  In the contemporary cultural climate in which accountability and evidence-based practices drive funding opportunities and program sustainability, health educators must better align philosophy and practice with research evidence.  With the goal of promoting health and a broad deterministic view of education, health educators can meet the challenge of improving the public’s health through changing social as well as lifestyle factors.