Professional Characteristics of Health Promotion: A Scoping Review of the German and International Literature

Objective: This scoping review investigates current developments in the professional characteristics of health promotion (HP) with a focus on the German speaking part of Europe. The conceptualization of HP is a prerequisite for progressing HP professionalization and clarifying the interconnectedness between HP and Public Health. Methods: The search strategy was informed by sociological professionalization theories. Original publications were included in a content-based analysis. Results: Ninety publications (37 original publications) were identified in the review. The results are summarized in categories based on professional characteristics: 1) profession, 2) ethics, 3) education/training 4) competencies, and 5) quality. The professionalization of HP regarding the professional characteristics is less developed in the German compared to the international literature. Conclusion: The mixed findings emphasize the relevance of a common HP conceptualization. The HP core competencies, which have been developed by the International Union for Health Promotion and Education must be further promoted. A strong HP workforce within Public Health strengthens the HP status in policy contexts and society and its contribution to promoting health and tackling social inequalities in health.


INTRODUCTION
In pursuing the overarching goal of preventing and managing health problems worldwide, health promotion (HP) offers valuable competencies that can contribute to political and societal efforts. With its focus on socioenvironmental determinants of health at a community level as described in the Ottawa Charta in 1986, HP has the potential to promote health and well-being for all groups of society [1,2]. In line with this increasing recognition of the relevance of HP, the United Nations explicitly referred to it in the Sustainable Development Goals for 2030 in goal 3: "Enable healthy lives and promote well-being for all at all ages" [3]. These goals are particularly important given that individualism, urbanization and globalization are driving many major contemporary health issues, including noncommunicable diseases, and call for rethinking our health systems with a strengthened focus on HP and prevention that complements the traditional focus on disease management and health care [4,5]. However, the often suboptimal quality of HP practice [6][7][8] and the lack of Public Health (PH) professionals [9,10] call for a stronger HP workforce. Although HP has come a long way since the 1980s, it is not wellestablished as a profession in our society yet, at least in the German speaking part of Europe [11][12][13][14][15].
For better comprehensibility the following section provides descriptions for the central terms in this article and their relation between each other referring to Mieg, 2016 [16]. Professionalization in this article is understood as an overall term for the development of the field of action of HP being performed by professionals. Within the professionalization process a main requirement is the conceptualization of the concrete field of action, which can then be described by specific professional characteristics. As identification of professional characteristics therefore represents a central building block to support the development of the HP profession, this study aims to provide an overview of the professional characteristics of the HP profession described in the literature. Thereby, professional characteristics don't capture the analysis of a whole profession but facilitate the understanding of different relevant aspects of a single profession. We understand professional HP as it was conceptualized in the Ottawa Charta: a salutogenic perspective on health focusing on populations based on the principles of participation, empowerment and health equity. HP is a multilayered concept to initiate a paradigm shift within our health systems to a state of Health in all Policies [1]. This means many professions are involved in this paradigm shift including a specific profession -the HP practitioner.
Professionals are needed to face complex challenges in today's knowledge-oriented societies, such as the promotion of well-being and population health. As systematic approaches to describe professional characteristics, a variety of sociological theories on professionalization have been developed since the early 20 th century. For instance, professional characteristic theories represent pragmatic approaches to the issue of professionalization that focus mainly on the institutional level, namely on education and training institutions, professional institutions or a code of ethics [17][18][19]. Since the 1980s, however, the focus shifted to the individual level of professions, such as the professional performance [20], competencies and professional identity [16]. A combination of different approaches that distinguishes the institutional level and the individual level of professionalization was then suggested by Mieg [16]. Summarizing these different professional characteristics on institutional and individual level [16][17][18][19][20] leads to the following shortened listing: 1) professional performance/professional identity 2) ethics/values, 3) education/training, and 4) quality/standards/ competencies. These professional characteristics are a helpful conceptual frame for analyzing the conceptualization of the HP profession and they are thus used to derive the research questions of this scoping review, which aims to provide an overview of current developments regarding the professional characteristics of HP.
While HP is clearly a central part of PH, it is important to consider how the two are connected [21,22]. As in HP, the professionalization discussion is also ongoing for PH [10,[23][24][25]. PH deals with a great variety of issues-including prevention, health care and tackling the social determinants of health [21,26] (e.g., see 10 Essential Public Health Operations; [27]) making PH very broad and complex to capture [10,26,[28][29][30]. Moreover, PH is described as research orientated [28,31], and still overlaid by biomedical principles [32,33] whereas HP is clearly practically orientated to address the socioenvironmental determinants of health at a community level with a bio-psycho-social perspective. PH has to recognize the necessity of specific skills for HP [34]. There are international efforts to foster the professionalization of HP that are illustrated by several indicators found in literature [2,14,21,22,[35][36][37] and shortly listed in Table 1. Although the specialization of competencies in HP is a desirable outcome to tackle todays' pressing health problems to foster quality standard in HP practice, a gradual separation between PH and HP represents a major challenge for HP and PH because the workforce capacity of each discipline may be reduced by a segregation of these interconnected disciplines. The professional HP development within PH is therefore a great concern to the workforce, which needs to be closely monitored in order to get the best of both worlds: a clear profile for HP professionals and a synergistic interplay of HP and PH. We argue that identifying the professional characteristics of HP in the literature helps to foster the conceptualization of HP which contributes to the professionalization and is a prerequisite for analyzing and optimizing the interconnectedness between the HP and PH professions. The aim of this study is therefore to provide an overview of the professional characteristics of the HP profession focusing on German compared to international literature.

METHODS
Literature on HP as a profession, especially empirical studies is scarce [11,15]. Therefore, we conducted a scoping review as it allows the inclusion of literature of lower scientific quality such as grey literature, and is well suited to gain a broad and explorative understanding of the research question and can even help to specify it [38,39].
As outlined in the introduction, a summary of different sociological professionalization theories referring to professional characteristics on the institutional and individual level [16][17][18][19][20] provided the conceptual background for the research questions of this scoping review. Four categories in which the professional characteristics are gathered were differentiated: 1) Professional performance/professional identity, 2) ethics/values, 3) education/training, and 4) quality/ standards/competencies. Building on the four distinct categories of the different sociological professionalization theories [16][17][18][19][20] described in the introduction we derived the following focal research questions: "What does the literature reveal about . . . 1) . . . the profession of HP, with a focus on professional identity and professional performance?" 2) . . . professional ethics/values of HP?" 3) . . . education and training in HP?" 4) . . . quality/standards or competencies of HP?" In order to systemize the search strategy, we applied the PICO scheme: P (opulation), I (ndicator), C (omparison), O (utcome of interest) [39]. Although, not all categories were relevant for the present research question, the scheme helped to specify the search strategy. All keywords, synonyms and the Boolean operators that have been used are shown in Table 2.
The search strategy employed three databases: CinahlComplete, PubMed and the International Bibliography of the Social Science (IBSS). The strategy was adapted to the search template in the database. Moreover, specific journals were screened (Global Health Promotion, Health Promotion International, Prävention und Gesundheitsförderung (German) and Spectra (Swiss) and Google Scholar was searched for grey literature. We also conducted a hand search in the references of relevant literature. The scoping review was conducted in March 2020.
Study selection was guided by inclusion criteria. We included 1) any kind of theoretical and original (empirical studies and literature reviews) literature, including journal articles and grey literature; 2) literature that focuses on HP as defined in the Ottawa Charta [1]; and 3) German as well as English literature in the review. The German literature represented a special interest of the authors who plan to conduct further research in the German speaking part of Europe (Switzerland). The inclusion of international literature supports the identification of potential opportunities and challenges within the conceptualization of the HP profession as many countries have advanced further in the professionalization of HP (e.g. Australia, New Zealand, Canada and Ireland) [6,22]. Finally, we D) limited the publication date to 2012 to 2020 as we expected the standardized competencies that were published by the IUHPE in 2011 in the CompHP core competencies framework of HP (37; German version in 2014 [40]) to impact the professionalization debate in HP. Figure 1 shows the search process including all literature identified (N 1880), those who were rated as relevant after screening the abstracts (n 119) andin a second screeningthe full texts (n 90). For the content analysis, we selected original literature only (n 37).
The data was collected in an Excel file containing relevant information: author, nature of literature (journal article, grey literature), year of publication, title, methods, aim, outcome and country study conducted (see Table 3). Data analysis was based on deductive and inductive principles. Within the deductive part, we categorized the data comparable to the professional characteristics as a theoretical basis of the search strategy. The data is described quantitatively using frequencies (see Table 4). For the inductive data analysis, we conducted a content-based literature analysis, which was only applied to original literature (n 37) (see Table 3).

RESULTS
The search strategy revealed 90 publications, of which 31 are in German language and 59 in English of which non was conducted in a German speaking region. In total, 37 original publications (empirical studies and literature reviews) published between 2012 and 2020 were identified, 24 of which were in English. An overall lack of empirical studies on the HP profession was noteworthily, especially in the German speaking countries but also internationally. Table 4 provides further details about the descriptive analysis of the scoping review results of all 90 publications.
The content-based analyses revealed five major categories: 1) profession, 2) ethics, 3) education/training, 4) competencies and 5) quality. As the focus and content of the literature identified in the 1 | International efforts to foster the professionalization of health promotion that are illustrated by several indicators found in literature [2,14,21,22,[35][36][37] (Professional characteristics of health promotion: a scoping review of German and international literature, Switzerland, 2021).
Indicators for professionalizing HP a internationally 1) Education and training programs in HP are established on an international level comprising bachelor's and master's degree programs and continuing education 2) Core competencies are defined in a HP framework on an international level [37] 3) Research units specialize in HP (e.g. at the Universities of Ireland and Bielefeld) and specific scientific journals are published (e.g. Health Promotion International, Global Health Promotion, Prävention und Gesundheitsförderung) 4) National and international conferences on HP are held (e.g. World Conference on HP) 5) National and international professional institutions are established, especially the International Union for Health Promotion and Education (IUHPE) 6) Accreditation systems are available and applied, such as the "IUHPE Registered Health Promotion Practitioner" 7) National and international political priorities are established on HP (e.g. UN Sustainable Development Goals (SDG 3) or the German law on prevention and HP) a HP: health promotion. scoping review partly differed from the professional characteristics that have been outlined in the sociological theories, we specified and adapted the names of the categories as follows: 1) "Profession" summarizes literature focusing on HP as a profession including professional performance and professional identity; 2) "Ethics" summarizes literature regarding ethics and values of the HP profession; 3) "Education/training" summarizes literature describing training programs and study courses in HP; 4) "Competencies" was separated from 5) "Quality" as a category because there were numerous publications found which either dealt with competencies of HP professionals-or with analyzing quality standards of HP practice. The content of the original publications is summarized in the following section (see Table 3 for more details of all 37 original publications).

Profession
Three publications in German language discuss the HP profession, focusing on education of HP [41], employees' perspectives on the profession [14] and an analysis of decision makers of HP interventions in Germany [42]. Overall, the study's results show unclear definitions and roles of HP practitioners, especially when practitioners are not having an education or training in HP or a related field [14,41]. The variety of existing health related study courses in Germany add to the intransparency of competencies and curricula [14]. These barriers hinder the development of a professional identity and the societal acceptance of the profession [14]. Compared to the German literature, the English literature (mainly Australia, Canada and United States) seems to fulfill higher quality standards as they mostly consist of peer-reviewed journal articles. Also, with respect to the content, English articles focus on specific aspects of professional performance in HP, such as critical reflection [43], sustainable practice [44,45] and on socioecological determinants in interventions [8]. However, English and German literature are both clear about the importance of specifically trained HP competencies [8,14,42,45]. These publications variously emphasized the value of a code of ethics, a meta theory in HP and a common professional profile including professional competencies that would help to promote professionalization of HP regarding professional identity and professional performance in HP.

Ethics
All six original publications identified are published in English (mostly Australia) and focus on the ethical aspects of HP practice. Some publications focus on defining ethical dimensions of HP [46,47], one focuses on challenges of empowerment applied in       The progress of CompHP implementation reflected the HP infrastructure and capacity in the countries. Major limitations were a lack of awareness of the CompHP also by main stakeholders and employees. The CompHP has to be promoted over the next years to build capacity of HP.  HP interventions [48]. Further publications accentuate the importance of the implementation of ethics into HP practice [49,50] and also national guidelines for HP [51]. It is evident that there is a substantial gap between theory and practice regarding HP ethics, despite ethical considerations being mandatory when planning and conducting interventions. As already recognized within the category "profession," a code of ethics in HP is needed and asked for [41,[46][47][48]50,51].

Education/Training
In total, nine original publications were identified that fit the category "education/training." German as well as English publications display a broad spectrum of thematic aspects. Some publications evaluate professional training programs in HP for different professions [52][53][54][55][56]. These publications demonstrate that persons employed in HP often don't have any professional knowledge about it [55]. There are also publications that study the HP competencies within a master's program in Public Health [32,57], which reveal major gaps in the curriculum addressing social determinants of health [32]. Finally, only a few publications focused on academic study programs in HP. Only two were found from German speaking regions [58,59] and these studies are not exclusively focusing on HP but also included related study topics courses.

Competencies
Competencies are the basis for professional performance. In total, nine publications were identified focusing on competencies in HP, two of them in German. The German publications don't focus on the CompHP [60,61] but developed an inclusive framework for PH, health sciences and HP study programs [59]. Most English publications focus on the development and implementation of the CompHP [6,[62][63][64], which is also adapted as an accreditation framework for HP practitioners [65]. Australia [66] and New Zealand [67] also edited own frameworks. The importance of common professional competencies is affirmed by all authors [6,[60][61][62][63][64][65][66]. It is seen as the basis for a common professional profile, for transparent professional competencies, for a common code of ethics and strong professional identities as HP practitioners [63]. For more detailed literature on the competencies, Battel-Kirk's and Barry's scoping review from 2019 can be consulted [63].

Quality
All five original publications focusing on quality assurance of HP and prevention interventions included in the content analysis of this scoping review were conducted in Germany. Their overall aim was to identify quality standards that can be used by primary stakeholders in HP and prevention [68][69][70][71]. Quality assurance of HP and prevention interventions are still fragmented and poorly standardized, although a standardization of tools and activities is agreed upon when resources are available. Regarding the quality of HP interventions as defined in the Ottawa Charta, one article detected an insufficient focus on social determinants of health or on projects based on the setting approach but a strong focus on behavior change programs [7].

DISCUSSION
This scoping review aimed to outline the actual developments of professional characteristics of HP with a focus on the German speaking part of Europe taking international literature into account. Of 90 publications that were identified, 37 were original publications and about one-third of the theoretical and original publications were contributions from the German speaking context. Based on the content-analysis, the results were summarized in categories that reflect the professional characteristics: 1) profession, 2) ethics, 3) education/training 4) competencies, and 5) quality. Content analysis was only applied to the original literature (n 37). Overall, HP is clearly developing as a profession especially in English speaking countries, as literature was identified regarding all professional characteristics [16] with the exception of the professional identity of HP practitioners. German original literature did not address "ethics" as a professional characteristic and only few publications considering "competencies" and "education/training" were identified. Thus, the discussion in the German original literature was mostly focused on the two specific professional characteristics of "education/training" and "quality." Furthermore, the quality of the German literature was lower than the international literature (i.e., more grey literature than peer-reviewed articles). Summing up the findings, the importance of a common code of ethics in HP, a meta theory in HP and a common professional profile including professional competencies are needed to promote professionalization of HP regarding professional identity and professional performance of HP practitioners.
In total, German original literature revealed that HP is rather unclear in its conception and establishment as a profession, as well as in terms of its relation to PH. The following factors contribute to the confusion and intransparency of HP at an educational level, within the labor market and in society. As described in the introduction HP is not mentioned to be an exclusive profession but is seen as a paradigm shift of our health system [1]. Therefore, on the one hand a wide range of professions (doctors, nurses, therapists, teachers, social workers etc.) are called to promote health and integrate the principles of the Ottawa Charta in their professional work: participation, empowerment, and health equity. On the other hand, we need HP professionals to initiate this paradigm shift, conduct specific HP projects and mediate between important stakeholder to foster Health in all Policies [12,34]. This can be contradictory and in conflict with the goal to define clear professional roles. There is a lack of studies describing the contents and learning outcomes of HP programs, which are needed to promote comparability and transparency of the programs to define the professional roles of HP practitioners. The confusion about health-related courses is reinforced by a great expansion of these programs since the Bologna process in 1999. Study programs are named very differently (health sciences, health communication, public health, health management, health promotion etc.) but competencies and curricula are overlapping [26,72,73] and seem to qualify students for HP practice. Educational institutions competitively advertise for potential students with a great variety of study programs which is fostered since the Bologna process. Mainstreaming of HP can be recognized in many health-related study courses. This mainstreaming of HP in diverse sectors of health [2,22,74] may lead to loss of quality of HP practice. To establish an efficient PH system including a strong HP workforce, collaboration with a common language has to be the goal instead of competing interests and economic factors at educational institutions. More specific HP programs must be established at universities with staff engaged in HP research and practice. PH has to recognize the specific competencies for HP, which are not sufficiently addressed in general PH programs, even less in other health professions' programs [34]. Literature identified in the scoping review conclude that higher education institutions are meant to play a significant role to clarify HP's roles, promote its societal status and coordinate initiatives to overcome the mainstreaming of HP [12,14,41].
Concerns about the quality of HP and prevention in practice were identified in German original literature in terms of the poor standards in planning, conducting and evaluating HP interventions [7,[68][69][70][71]. Most interventions are not based on a setting approach and do not focus on social determinants of health at a community level but address individual behavior change instead [7]. Of course, the debate about the quality in HP practice is inherently linked with competencies and the education or training of persons working in the field. Both, the German and English literature point out that there is a lack of expertise and professional knowledge in HP practice [6,7,14,42,45]. Therefore, the CompHP framework by the IUHPE is a good basis to build on, for educational purposes, for the labor market to prioritize professional profiles, as well as for governmental guidelines for HP [37]. The international literature reveals few publications on competencies in HP, mostly the CompHP, but the implementation in the different countries is progressing slowly [6,64]. The German version of the CompHP was published in 2014 [75]. Whereas original literature showed no reference to the CompHP in 2015 [60], theoretical publications in 2018 indicate the rising recognition of the CompHP also in the German speaking part of Europe [75,76]. Battel-Kirk and Barry (2019) point out that the implementation progress of the CompHP reflects the professionalization of HP in the particular country [6,64]. The competency framework for HP is meant to strengthen professional identity and roles of the HP workforce [63]. Major challenges for the implementation are structural aspects, e.g. political commitment to HP, lacking differentiation between HP and PH, a weak HP workforce and lacking knowledge about the CompHP. Facilitators are a strong HP professional institution, national accreditation of HP and HP education [6,63]. Therefore, the CompHP influences all professional characteristics of HP, namely professional performance and professional identity, ethics/values, education/training and competencies/quality. Two further initiatives are mentioned which promote clarification regarding the professional characteristics of HP: Quality of HP practice in the German speaking countries is enhanced by "Quintessenz" a widely known online network and projectmanagement-tool, which ensures a systematic and high quality proceeding in HP practice [77]. An internationally committed code of ethics in HP still needs to be established. Besides the CompHP the code of ethics of health education professionals in the United States [78] can also be drawn upon. There have been made great professional achievements in HP within the last years (see Table 1). Therefore, we need a young professionally trained HP workforce to further promote their visibility and competencies to address actual and future challenges of society's health.

Limitations
Searching the databases and journals revealed an abundance of English literature but a scarcity of German literature. Therefore, we conducted an extended search for grey literature in Google Scholar and a hand search for the German literature. This may have led to an increased amount of grey literature in the German relative to the English literature. As the main aim of the scoping review was to identify professional characteristics of HP in the German speaking part of Europe with comparison to the international literature, this limitation should not invalidate the findings. Further, abstracts and full texts were only singlescreened, which represents a methodological limitation. However, this proceeding is often applied in scoping reviews and can even be justified for systematic reviews [79].

Conclusion
Analyzing international literature on professional characteristics of HP reveals the necessity of clarifying competencies and the professional profile of HP. The lack of expertise and professional knowledge in HP practice in the German speaking part of Europe as well as internationally [6,7,14,41,44] indicates the need for clarification regarding specialized competencies of HP within the PH field. Therefore, integrating the CompHP in national and regional HP institutions, at an educational level, as well as in relation to the workforce and labor market would help to address these needs. The lack of recognition of the CompHP is evident in the identified literature, especially in the German speaking countries, and must be of concern in future investigations on the HP profession. The unclear relationship and differentiation between HP and PH further hinders the conceptualization of the HP profession [6,62]. Higher education institutions play a major role in clarifying the interconnectedness between HP and PH, addressing this by adapting curricula and names of their study programs. HP as a profession and HP professionals would benefit from being trained based on the CompHP, which reflects professional competencies for HP based on the Ottawa Charta. Transparency and comparability of competencies of the HP, PH and the wider health workforce contribute to the political and societal recognition of important professions in national and international efforts to tackle rising social inequalities of health and global health issues (infectious and non-communicable diseases).

AUTHOR CONTRIBUTIONS
VB developed the conceptual idea, conducted the scoping review and wrote the manuscript. TG supervised the project and contributed to the manuscript. FW contributed substantially to the conceptual idea of the project and the manuscript and supervised the project.