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Initial and Further Education in Health Promotion and Disease Prevention

Beate Blättner, Thomas Hartmann, Kerstin Baumgarten

(last update 14 January 2015)

The ways in which one can become qualified in the areas of health promotion and prevention have expanded considerably in Germany over the past 15 years, especially at the university level. Health promotion and prevention are increasingly using modern scientific methods to determine true needs, for example, by employing socio-epidemiological studies and health reports as well as by testing the efficacy of interventions in accordance with rigorous methodological criteria (evidence-based health promotion). Consequently, further academization seems likely, especially when dealing not with changes to individual behavior patterns, but with organizational developments in human settings.

Formally speaking, any type of qualification must be seen as part of the educational and professional system. Education in this context refers to a professional diploma or certificate of some nature that is recognized by the profession in question (e.g., as stipulated by the German Vocational Training Act (Berufsbildungsgesetz, BBiG)) or by educational institutes (e.g., a bachelor diploma from a university). Further education in turn presumes the existence of a recognized certificate of completion and results in achieving additional recognition, for example, a master’s diploma or some other sort of certificate recognized by federal state law or professional organizations (e.g., a dental prophylaxis assistant). Certificate courses that do not meet these criteria are considered unregulated advanced training, regardless of where they are offered.

Positions in the area of health promotion and prevention do not belong to those areas regulated as health professions in Germany. In consequence, there are no such established and qualified professions. Designations such as health counselors, preventologists or health pedagogues have been trademarked, but they are presently not legally protected terms. Thus, diplomas from recognized educational institutions remain the only way to achieve official recognition of further education in health promotion or prevention.

The present recommendations prepared by the statutory health insurance companies (2010) differentiate between individual actions, those taken in the scope of company-wide health promotion and those directed toward life settings (setting approach). For individual prevention measures the following demands have been set down for the providers of such measures: The provider must possess the basic qualification of having an officially recognized vocational or professional diploma in the respective field; he has obtained additional qualification(s) gained through professionally recognized further education; and, if necessary, he has received instructions in the respective program to be carried out. In addition, teaching skills and - inasmuch as the program is directed toward persons from socially disadvantaged backgrounds - social-pedagogical skills should be documented. Thus, for example, carrying out a program with the preventative goal of “reducing physical inactivity through sports activities” could entail having a qualification as physiotherapist, possessing a diploma in sports science or being officially licensed as a training instructor or gymnastics teacher.

When determining the necessary qualification, one must differentiate between the professional qualification and the required skill level. Technically speaking, a non-academically trained dietician and a research nutritionist are both qualified to lead group counseling sessions on matters of nutrition, if they have the necessary teaching skills to do so. In terms of their skills level, though, they differ considerably according to their formal education. Though they are both generally qualified to present standardized course materials from prepared materials and handouts, the development and evaluation of such concepts demand similar professional qualifications but different skills levels.

The discussion surrounding the respective skills level runs parallel to the strategy proposed by the European Council of creating a system of education and continuing education that is horizontally vertically and transnationally permeable and allows life-long formal and informal learning to become the basis for a Europe-wide “society of knowledge.” The premises for this are complete transparency and the reciprocal acknowledgement of qualifications throughout Europe. To this end, the European Commission established a European Qualifications Framework (EQF) that provides descriptors of knowledge, abilities and responsibility at eight different levels. Level 6, for example, corresponds to completion of a Bachelor’s degree, level 7 to that of a Master’s degree.

Further descriptors serve to differentiate the level at which decisions are made and how the knowledge necessary to that end can be scientifically quantified. For example, level 5 could demand the ability to carry out a standardized course concept in prevention; the inherent latitude at this level refers to how a given concept is implemented with the respective course group. Level 6 in turn comprises leading a project concerned with health prevention; level 7 to developing new strategies of intervention and the further development of the theoretical and empirical basis of health prevention. With each advancing level the discretion available as well as the complexity of the background and the fragmentary nature of the information being inputted increases. On level 7, research is not simply being acquired anymore but created.

In order to implement the EQF, 36 European countries proposed the development of National Qualifications Frameworks (NQF), including Germany. The working group German Qualifications Framework (GQF) adapted  formal qualifications to the levels of the EQF. Professions concerned with prevention and health promotion without university degrees are no longer listed since they do not represent formal training. Health professions such as qualified medical/dental employees and nurses/healthcare specialists were assigned to level 4 as assistant professions. Level 4 comprises skills of independent planning and execution of professional activities in a broad and changing area or professional field. In contrast, level 6, the Bachelor’s degree, comprises skills necessary for planning, carrying out and evaluating broad professional activities and problems as well as autonomously controlling such processes. The specific requirements are characterized by the complexity and the rapid changes that typically occur in interventions in such settings. A third type of differentiation goes back to the work of Griffiths and Dark, who developed a skills framework for health promotion based on literature research and expert interviews for the National Health Service in England and Wales. They differentiate, on the one hand, between specialists for health promotion in the narrower sense and professional groups responsible for health promotion in the broader sense as well as between activities directed toward individuals and those directed toward population groups. For example, someone who teaches courses in health promotion is engaging in a prevention activity geared toward individuals, whereas a healthcare specialist or nurse may interact with individuals as well as engage in prevention activities although not specialized in that area. The preparation of health reports and prevention goals are other examples of activities of health-promotion specialists directed toward population groups, whereas community politics generally deals with health promotion in the broad sense of the term. Each of these practices would clearly require a different qualification.

Nutrition scientists/researchers and sport scientists/researchers as well as other professional groups that, in a broad sense of the term, play a special role in the field of health promotion enjoy long-established academic or nonacademic professional training. Training for persons in other health-related professions, such as physiotherapy or dietetic treatment, are generally not internationally recognized professional training but rather courses of study. Thus, in Germany, in the future such training will necessarily have to become integrated into the academic structure. Model courses of study of this nature are now being field tested until 2017.

Up to the mid-1990s in Germany there was no officially recognized training available for working in the fields of health promotion and health prevention. Continuing education usually was held as part of nonregulated, either privately or publicly organized, adult education. This changed with the introduction of the first courses in public health. In 1989, after a 2-year preparatory phase, the German government started a funding initiative with the goal of establishing internationally competitive structures for research and teaching in public health at the university level. Between 1989 and 1995 the five research associations that had received this funding established nine postgraduate university-level study courses for public health concluding with the degree of MPH (“Master of Public Health”) or MSP (“Magister Sanitas Publicae”), both of which were based on similar standards. At approximately the same time the first courses of study concluding with a diploma at the polytechnical level were established for health promotion and health management, both of which were similar in nature to the training employed in social work.

The so-called Bologna process triggered a new phase after the year 2000: the development of a Europe-wide university landscape with comparable degrees. The study of health promotion or public health has since been established as a three-step system: the bachelor’s degree as the initial academic degree, to which the master’s degree can be added, and as proof of scientific eligibility the doctorate. The first two degrees do not differ whether obtained from a university and or from a polytechnic, and there is presently a push to establish doctorate programs at the polytechnic level. Simultaneously, the external accreditation of study courses (a formal assessment of quality standards) was introduced to review the general criteria involved (e.g., feasibility, agreement with formal criteria and resources). Possible degrees are the Bachelor of Science (B.Sc.) or the Bachelor of Arts (B.A.), which are equivalent in nature and are delineated from each other only by whether the courses have a medical (B.Sc.) or a social sciences background (B.A.). In the Master’s study courses, besides the Master of Science (M.Sc.) and the Master of Arts (M.A.), there is also the Master of Public Health (MPH), which is a nonconsecutive Masters course, that is, it does not build on some other associated course of study. Here, too, this type of degree does not reflect a quality standard.

There are presently 13 accredited Bachelor courses of study and 25 Master courses of study that prepare students to work in the field of health promotion or public health. There also exist further courses of study that combine health promotion with, for example, other special fields such as sports, nutrition or mental health. The title of a particular course of study does not necessarily reveal whether it is suited for activities at the individual level (health education, health literacy) or at the level of population groups (corresponding to the setting approach) - or a mixture of the two. Some universities also offer scientifically based further education (formally speaking these are continuing education courses) in health promotion which are also available to persons without access to university education; participants are given a certificate. Private for-profit providers or providers of publicly sponsored adult education also offer a number of courses in continued education providing certificates that are not necessarily legally or professionally accredited.

In order to improve the transparency toward both students and potential employers, a panel of experts from the German university system developed a national Professional Qualification Framework (PQF) that may be employed at the vertical level of the Dublin descriptors and at the horizontal level of the Public Health Action Cycle to describe the necessary skills. Table 1 shows the respective descriptions for level 6, which corresponds to the initial university degree. Such suggestions, however, are not binding for the universities, though the skills mentioned are generally accepted.

A different path may be found in the list of skills developed by the International Union for Health Promotion and Education (IUHPE) and in the list of core competences published in German by the BZgA (ComHP), which foresees a certification and registration system for specialists and certain training courses. In light of the large sums that have already been drawn from public sources to ensure the accreditation of such courses of study as well as those that would be necessary in the future for registering the courses, this development may be seen critically, especially since it is taking place in a country that has yet to even prepare a register of all health professions. Health prevention and health promotion should be subjected to regulations that are more stringent than those applied in the fields of nursing and medicine. A course of study is, after all, a state-approved degree.

Public Health Action Cycle/Dublin-Descriptors

Problem determination  
Ascertaining the need for actions

Formulation of policy
Ensuring the realization of the parameters

Ensuring the realization of the parameters

Assessment of the actions, projects and studies

Knowledge and understanding
Ties in with at least some aspects of the state-of-the-art research

Is aware of the various determinants of health and of the methods employed to determine the needs and demands for health-promotion measures  

Is aware of the strategies and action fields of health promotion of the WHO as well as the national developments and the respective scientific theories cited

Is aware of the relevant parameters of health promotion and of the structures of the social and healthcare systems as well as of the foundations of national social and healthcare policies

Is aware of the methods used in quality management to test measures of health promotion

Applying knowledge and understanding
Formulating and substantiating arguments, solving problems  

Ability to determine which target groups, settings and fields of health promotion are relevant; ability to use data sources and methods of empirical social research to determine needs, identify and collate demands

Ability to develop and substantiate appropriate (evidence-based) concepts, strategies and actions for behavioral change with respect to the target groups, settings and themes

Ability to decide which parameters are necessary for which type of intervention and how these interventions can best be implemented with the available means of the project management using participatory approaches

Ability to do empirical research on actions and autonomously evaluate the success of own interventions using the methods of qualitative and quantitative social research together with applicable methods and instruments of quality assurance

Making judgments
Collection and interpretation of relevant data to support own evaluations reflecting the relevant social, scientific and ethical concerns

Makes conclusions from existing and own data with respect to individual and population-based health resources, risks and stresses in order to determine the need for actions based on scientific, social and ethical premises; reflects particularly on the influence of social inequality, age and sex

Draws up strategies, approaches, methods and actions based on relevant data and theories and adapts them to everyday and project-based parameters; reflects on ensuing problems

Makes decisions on specific interventions with specific target groups and reflects on the ramifications these actions could have on other health-related and social fields; sets priorities according to social and ethical considerations

Empirically evaluates the success of interventions and assesses their ethical, scientific and social relevance

Facilitates ideas, problems and solutions to both experts and the general public

Ability to properly communicate and facilitate the results to the general public, persons directly affected, experts and decision-makers

Ability to communicate the premises and approaches to the general public, persons directly affected, experts and decision-makers; able to transparently present and integrate both own opinions and those of others

Ability to carry out actions cooperatively in a professional team and implement them with the participation of the target groups; able to communicate to the decision-makers how the decisions came about and what their consequences are; able to organize and carry out information exchanges among experts

Ability to facilitate both verbally and in writing the critical, reflected evaluation of strategies, approaches and methods of health-promoting projects to diverse audiences

Learning skills
Learning strategies to enable continuing studies independently

Ability to apply strategies for systematically filling information gaps with the basics of scientific research

Knows strategies for learning from past experiences to develop new actions; able to develop new approaches using the basics of scientific research and to work with them within the team

Ability to reflect on and further develop methods and results and to relate them to own and general scientific knowledge

Ability to use own and others’ results from evaluation to optimize methods and strategies

Table 1. Bachelor of Health Promotion: Curriculum of studies directed toward population groups or mixed form.

Blättner B, Kompetenzprofil für Gesundheitsförderung, in: Rásky E (Ed.): Gesundheitsprofi(l) für die Pflege, Wien 2008, pp. 123-140.
Blättner B/Heckenhahn M, Professionalisierung in der Gesundheitserziehung, Bern 2009, pp. 254-264.
Europäische Kommission, Der Europäische Qualifikationsrahmen für Lebenslanges Lernen (EQR) 2008.
Available online at
GKV Spitzenverband, Leitfaden Prävention, Handlungsfelder und Kriterien des GKV-Spitzenverbandes zur Umsetzung von §§ 20 und 20a SGB V vom 21. Juni 2000 in der Fassung vom 27. August 2010, Berlin 2010.
Griffiths J/Dark P, Shaping the future of public health: promotion health in the NHS. Project report. The role of specialized health promotion staff in improving health, London und Cardiff 2005.
BZGA (Ed.) Das CompHP-Rahmenkonzept für die Gesundheitsförderung. Kernkompetenzen - Professionelle Standards - Akkreditierung, Deutsche Kurzfassung, Köln 2014,
available online at

Internet addresses:
www.deutsche-gesellschaft-public-health.de (homepage of the umbrella association German Society for Public Health)
www.hs-kompass2.de/kompass/xml/akkr/maske.html (database of accredited courses of study)
www.iuhpe.org/index.php/en/the-accreditation-system (homepage der International Union for Health Promotion and Education, with explanations of the accreditation system)
www.dqr.de/ (homepage of the German Federal Ministry of Education and Research concerning educational qualifications in Germany)

Links: Health Education, Setting Approach

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Federal Centre for Health Education (BZgA) / Maarweg 149-161 / 50825 Köln / Tel +49 221 8992-0 / Fax +49 221 8992-300 /
poststelle(at)bzga.de / E-Mail for Orders: order(at)bzga.de

The Federal Centre for Health Education (BZgA) is a specialist authority within the portfolio of the Federal Ministry of Health.