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Chapter 1
Considering the politics and practice of health education
Katie Fitzpatrick and Richard Tinning
Introduction
The āhealthinessā of young people and communities dominates news and entertainment media in many countries and is at the centre of a raft of academic work. As Ayo (2012) argues, āhealth consciousness has become deeply engrained within our social fabricā (p. 100). Current health issues that dominate public discussion and research publications include everything from alcohol and drug use, parenting, teenage sexual behaviour and pregnancy, through to suicide, obesity and poor nutrition. Issues of safety, risk and decision-making are invariably implicated, along with more traditional calls for the prevention of illness. Attending to the āburdenā of non-communicable, or lifestyle, diseases is currently favoured in Western countries as people from all levels of society are targeted with advice on how to be healthier. These issues are addressed at the level of the state in the form of āhealth promotionā and within schools in the form of āhealth educationā (although these terms are used by scholars and practitioners in a range of different ways, which we discuss below).
The visibility of such health discourses is a form of public pedagogy. Advocates of this pedagogy employ moral imperatives to enable people to self-monitor, regulate and medicate their bodies in the name of health. Over thirty years ago, Robert Crawford (1980) coined the term āhealthismā to describe the proliferation of health messages and the expectation that oneās health is essentially an individual responsibility. Healthism extends beyond the boundaries of illness and physical health concerns, crossing over into body maintenance, control and intervention. It operates at the individual level and assumes, as Crawford (1980) noted, a ānon politicalā agenda. For this reason, he argued that such a narrow and individualistic approach was an ineffectual method of health promotion. Later commentators have discussed healthism in relation to ānew public healthā that, according to Petersen and Lupton (1996), requires individuals āto manage their own relationship with and to the risks of the environment, which are seen to be everywhere and in everythingā (p. ix, emphasis added). Despite the critique by health sociologists, that managing such risks is neither possible for individuals (Balbones, 2009; Morrell, 2009) nor necessarily desirable for mental health (see Burrows & Sinkinson, Chapter 12, this volume), the risk approach is commonly used in health education and health promotion.
In addition to health promotion becoming a form of public pedagogy, health also has an overt and explicit place in the formal education and schooling of young people. Schools are increasingly held up as sites of blame for health problems and called on to respond to health by āeducatingā young people to be healthy (Gard & Wright, 2005). Indeed, some form of health education is taught in most schools in North America, the UK, Australia and New Zealand as well as throughout Europe and Asia. While the approach varies widely between contexts, health education textbooks for teachers show that programmes include topics as diverse as sexuality education, nutrition, exercise, drug education, stress management, relationship skills, parenting and self-esteem (for example see Gilbert, Sawyer, & McNeill, 2011; Glanz, Rimer, & Viswanath, 2008; Read, 1997). The writers of such texts tend to advocate a broad view of health education but there is little doubt that schools are increasingly under pressure to educate for behavioural change and to monitor health practices and the bodies of young people. Particularly in response to the media profile of obesity, body monitoring, in the form of measuring body mass index and fitness tests, is undertaken in many schools (see, for example, Powell & Fitzpatrick, 2013). In this sense, school health education, alongside physical education, may be involved in the regulation and enforcement of particular health norms (Fitzpatrick, 2011; Wright & Harwood, 2009).
While this book seeks to investigate health education both at a political level and with regard to school practice, it also attempts to comment on what kind of health education might prove useful (see, this volume: Fitzpatrick, Chapter 13; Leah & McCuaig, Chapter 16; Quennerstedt & Ćhman, Chapter 14; and Tinning, Chapter 15). Groups that advocate for greater attention to health have real fears that, if left unchecked, some health issues will continue to escalate to the detriment of future generations, both socially and economically. Critical health commentators assert that schools have a responsibility to critique and, where necessary, resist many health messages and policies and instead engage young people in learning about, rather than for, health. The social and political environments surrounding and framing health issues, however, also require attention (see, this volume: Hokowhitu, Chapter 3; Gard & Vander Schee, Chapter 5; and Powell, Chapter 11). How discourses of the body, gender and racialisation, as well as social class, physical environments and cultures affect and reflect health is also worthy of attention (see Fitzpatrick, 2013; Allen, Chapter 7, this volume).
In this opening chapter we overview a range of tensions and terminology in the field of health education. We specifically explore the following notions, which authors in this book take up in their chapters in diverse contexts: healthism and risk; health fascism; neoliberalism and the relationship between health education and physical education. First, however, we explore the messy terrain surrounding the terms āhealth promotionā and āhealth educationā.
Health education and health promotion
There is general confusion in the field concerning the terms health promotion and health education. While the latter is usually employed with reference to school curriculum, the meanings of the two are often confused and/or they are used interchangeably (see Macdonald, Johnson, & Leow, Chapter 2, this volume). With reference to community nursing practices, Whitehead (2003) differentiates between health education and health promotion in the following way:
Traditionally, health education activity is associated with behaviourally focused medical/preventative approaches to practice. Health education strategies are usually firmly rooted within biomedically positivist frameworks that advocate the use of reductionist, mechanistic, individualistic and allopathic [conventional medicine] activities in health interventions. Health promotion strategies, on the contrary, are usually associated with broader empowerment-based and socio-political approaches that concern themselves with community-based social, environmental, economic and political determinants of health care.
(pp. 796ā797)
This is interesting because, as Whiteheadās (2003) assertion suggests, outside of education, the term health education is more likely to be aligned with behavioural and biomedical approaches to the discipline. These might include transmission approaches to sharing information or behavioural change models such as the transtheoretical model (TTM) (Prochaska, Redding, & Evers, 2008). The TTM lists a series of stages that individuals proceed through as they seek to alter their health behaviour (for example, giving up smoking). Researchers using the model make recommendations for health professionals seeking to support individuals to permanently change certain behavioural patterns in their lives.
Health promotion then, according to Whitehead (2003), is more concerned with empowerment (although one might argue that the TTM is a model of personal empowerment, just one focused on the individual). The key difference Whitehead is pointing out here, however, is that health promotion is more likely to take into account the social, economic and political determinants of health and address change at a macro level. Confusion exists here because many school-based health educators, at least in the contexts we are familiar with, would claim to be doing exactly that: empowering young people to act on their own health concerns, while acknowledging the socio-cultural and political contexts within which health decisions occur. In reality, health education in schools tends to be a mixture of both of the definitions evident in the quotation from Whitehead (2003) above. Galstaldo (1997), indeed, argues that there are two dominant models of health education: a more traditional approach, which is founded on highlighting the individual āresponsibility for health and disease preventionā, and one that focuses on āempowering people to control their own healthā (p. 117).
Health education in schools has always had strong links with public health and state-sponsored interventions aiming to prevent and mitigate various societal health problems. There has been, and possibly still is, a failure to differentiate between public health policy and health education in schools (Gard & Leahy, 2009). Health education has its roots in biomedical views of health that tend to define health and wellbeing as the absence of disease. While this is pervasive, it is by no means the only discourse operating in health education. Commers (2002) argues that, although health education has consciously attempted to distance itself from biomedical disciplines, it nevertheless includes a great deal of epidemiology. In response, Commers advocates the voices of local communities in all forms of health education, arguing that āmost of the stressors which threaten the health of individuals and populations are well known to the individuals and populations they affectā (p. 47). Aaron Antonovsky (1979), a theorist of health aetiology, argued for more emphasis to be placed on what he termed a āsalutogenicā notion of health, which highlighted wellness and its causes rather than illness (see Quennerstedt & Ćhman, Chapter 14, this volume). Health educators such as Nutbeam (2000) suggest that health education should include the development of personal, social and political health knowledge and skills.
Harrison and Leahy (2006) argue that āthe health field is still dominated by psychological models that focus on individual behaviour change while paying lip service to the social determinants of ill-healthā (p. 152). In the end, however, as Gard and Leahy (2009) observe, health education āis comprised of a āpiling upā of past and present knowledges and practices related to health, health promotion, health behaviour, health education and education more generallyā (p. 184). It is no wonder, then, that terminology and approaches are frequently confused. In a text on health and physical education, Dinan-Thompson (2009) offers the following definitions:
ā¢ Health promotion
According to the World Health Organization (WHO) (1986), health promotion is the process of enabling people to increase control over their health in attempts to improve overall health. Successful health promotion requires multiple initiatives directed across individual community, social, environmental and political levels.
ā¢ Public health policy
Plans created by governments designed to monitor and improve the health of populations. Policy and action is focused on prevention, health protection (through laws and regulations) and health promotion (Dinan-Thompson, 2009, p. 183).
ā¢ Health education
The principle by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance or restoration of health.
ā¢ Healthy lifestyles education
A form of health education that emphasises the need for individuals to make āhealthyā choices in their life (Dinan-Thompson, 2009, pp. 183ā184).
Depending then on how health is defined, approaches to health education in schools will be diverse. Local context is clearly important and the role of the state and other, non-government, organisations in health-based interventions will also vary widely internationally. However, regardless of the approach taken, we suggest that health education has the potential to reinforce an obsession with health, or healthism (Crawford, 1980). We argue that healthism takes on a particular flavour in contemporary times as it is reimagined along neoliberal lines and suggest that it can, potentially, be understood as a form of health fascism. We explore these concepts next.
Healthism and risk pedagogies
Notions of healthism are inseparable from the fields of health education and health promotion. The desire to improve health seems to drive many people to monitor their bodies and stems from a concern for being healthy, eating healthily and behaving in health-enhancing ways (see De Pian, Evans, & Rich, Chapter 10, this volume). While this may seem like an unproblematic āgoodā, the general obsession with health in contemporary times has some curious outcomes. Robert Crawford (1980), whom we mentioned earlier in the introduction, defined healthism as:
the preoccupation with personal health as a primary ā often the primary ā focus for the definition and achievement of wellbeing; a goal which is to be attained primarily through the modification of life styles, with or without therapeutic help. The etiology [study of disease causation] of disease may be seen as complex, but healthism treats individual behaviour, attitudes and emotions as the relevant symptoms needing attention.
(p. 368)
Crawford questioned whether a focus on individual behaviour was likely to have any effect, given the complex social and political conditions within which choices about health occur. For example, a personās choice to exercise or not is greatly influenced by the community s/he lives in, access to resources, means of transport, local cultures that may or may not value sport or physical activity and so forth. Simply assuming that any individual has equitable access and can make health-enhancing choices ignores the complex interplay of surrounding social and cultural environments (see Hokowhitu, Chapter 3, this volume). As Crawford argued:
For the healthist, solution rests within the individualās determination to resist culture, advertising, institutional and environmental constraints, disease agents, or, simply lazy or poor personal habits. In essence then, cause becomes proximate and solution is constructed within the same narrow space.
(p. 368)
Crawford differentiated healthism from what he termed āthe new health consciousnessā, which he defined as a broader construct, encompassing: āenvironmental and occupational health concerns as well as concern for personal health enhancement ā¦ [and] variously developed political understandings of how social forces and processes systematically encourage unhealthy individual behaviour, often for private advantageā (p. 368; see also, Powell, Chapter 11, this volume).
Importantly, healthism is compatible with the new public health in which individuals are expected to be continually monitoring and managing the risks associated with contemporary living (Petersen & Lupton...
