Health Promotion

Planning & Strategies

Jackie Green, Ruth Cross, James Woodall, Keith Tones

• Publisher: SAGE Publications Ltd
• Year: 2019
• ISBN:
  9781526470980
• Edition: 4
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Globally recognized as the definitive text on health promotion, this fourth edition becomes ever more useful for public health and health promotion courses around the world. It offers a firm foundation in health promotion before helping you to understand the process of planning, implementing and assessing programmes in the real world. New to the 4 th Edition:

• A chapter on "Evidence-Based Health Promotion" addressing the development of an evidence base for health promotion.
• Expanded coverage of health inequalities, equity and social exclusion
• Further discussion of mental health promotion and well-being
• Key concepts are now highlighted and explained throughout the book
• ?Critical reflection' boxes have been added to help the reader think critically about an issue or approach.

The book issupported by online resources with up to 20 original case studies from around the world, access to full SAGE journal articles, and seminar questions for lecturers.

1 Health and Health Promotion

Overview

This chapter focuses on three broad areas – the concept of health, setting out the distinctive features and values of health promotion and establishing the position of health promotion vis-à-vis modern multidisciplinary public health and health education. It will:

• explore alternative conceptualizations of health
• develop a working model of health
• consider the ideology and core values of health promotion
• identify different models of health promotion
• set out the rationale for an empowerment model of health promotion
• locate health promotion within modern multidisciplinary public health
• propose a new ‘critical’ health education as the major driver and distinctive voice of health promotion.

Introduction

The primary concern of this book is to provide insight into the factors that contribute to the effective and efficient design of health promotion programmes. The way in which health is conceptualized has major implications for planning, implementing and evaluating programmes. Equally, the approach adopted at each of these stages will be influenced by the values of those working to promote health.

Health as a contested concept

Developing clear goals will depend on how health is defined. Yet, it is acknowledged that health is, as Gallie (1955) famously described, a contested and elusive concept, a notion which is widely accepted (Duncan, 2007). Its many, often conflicting, meanings are socially constructed. Lowell S. Levin likened the task of defining health to shovelling smoke. It is difficult, to say the very least, to provide precise definitions, largely because health is one of those abstract words, like love and beauty, that mean different things to different people, a point reiterated by Warwick-Booth et al. (2012). However, we can confidently say that health is, and apparently always has been, of significant value in people’s lives. If we do not acknowledge the contentious nature of health and have a sound understanding of the determinants of our preferred conceptualization, it is unlikely that we will be able to develop incisive strategies for promoting it.

Defining health: contrasting and conflicting conceptualizations

A number of tensions emerge in defining health. These include the relative emphasis on:

• disease or well-being
• holistic or atomistic interpretations
• the individual or the collective
• lay or professional perspectives
• subjective or objective interpretations.

One of the most persistent distinctions between definitions of health has been whether the focus is on wellness or on the absence of disease.

As Dixey et al. (2013a: 14) argue, it is very difficult, if not impossible, to reach a consensual definition of what health is. Probably the best known definition of health comes from the Constitution of the World Health Organization (1946, 2006a): ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ While this definition has been criticized because of its utopian nature, and as impossible to achieve (Blaxter, 2010), it extended the boundaries of health beyond the absence of disease to include positive well-being and firmly acknowledged the multidimensional, holistic nature of health. The Constitution further asserts that:

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

This assertion, also enshrined in numerous United Nations human rights treaties such as the International Covenant on Economic, Social and Cultural Rights (Office of the High Commissioner for Human Rights (OHCHR), 1966) and the Universal Declaration on Human Rights (UN, 1948), politicizes health and places pressure on governments to create the conditions supportive of health (WHO, 2007a). Furthermore, this emphasis on health as a fundamental human right focuses the attention of those seeking to promote health on equity and empowerment.

We have seen understandings about subjective health turn more towards notions of happiness, well-being, mental health, resilience and assets. This potentially makes the limits to health boundless, leading to all problems becoming ‘health’ problems and possibly unleashing unlimited demands for health services. It could arguably, therefore, undermine health and human rights arguments. Some argue for more attention to be paid to notions of ‘well-being’ and quality of life.

Lay interpretations of health

Notwithstanding the undoubted difficulties associated with measurement, from a health promotion perspective, the subjective element – health as it is experienced in people’s lives – is of central importance. Buchanan (2006), who has defined health as synonymous with the ‘good life’, emphasizes the importance of subjective, autonomous interpretations:

we should shift the emphasis in the field from the rather narrow focus on producing specimens of physical fitness, to a broader concern for human wellbeing, here understood in terms of enhancing moral judgment, promoting greater self-understanding, liberating people from scientistic assumptions (perpetuating the belief that human behavior is determined by antecedent causes that only highly trained scientists can divine), advancing the cause of social justice, and promoting respect for the diversity of understandings of the good life for human beings. (2006: 302)

This draws attention to lay interpretations of health that will be considered more fully in Chapter 2. However, for now it is relevant to observe that lay interpretations are complex and multidimensional. The absence of disease is central to lay views, but resilience – the ability to cope with life – and functional capacity are also important. Social class differences have also been noted (Blaxter, 2010; Calnan, 1987), with a greater emphasis on the ability to function in lower social classes and a more multidimensional conceptualization including positive well-being in higher social classes. Lay interpretations of health inequalities also differ (see Abstract 1.1). While lay interpretations are often taken to be different from more systematized ‘professional’ accounts, commonalities do exist. Lay accounts – particularly public as opposed to private accounts – tend to incorporate knowledge and understandings developed in expert paradigms (Shaw, 2002). One of the difficulties that we have in establishing lay beliefs about health is that much of the research that claims to explore these actually focuses on ill-health and dis-ease rather than on more positive notions of health (Hughner and Kleine, 2004).

Abstract 1.1

‘How the other half live’: Lay perspectives on health inequalities in an age of austerity. Garthwaite, K. and Bambra, C. (2017)

This paper examines how people living in two socially contrasting areas of Stockton on Tees, North East England experience, explain, and understand the stark health inequalities in their town. Participants displayed opinions that fluctuated between a variety of converging and contrasting explanations. Three years of ethnographic observation in both areas (2014–2017) generated explanations which initially focused closely on behavioural and individualised influences. Findings indicate that inequalities in healthcare, including access, the importance of judgemental attitudes, and perceived place stigma, would then be offered as explanations for the stark gap in spatial inequalities in the area. Notions of fatalism, linked to(a lack of) choice, control, and fear of the future, were common reasons given for inequalities across all participants. We conclude by arguing for a prioritisation of listening to, and working to understand, the experiences of communities experiencing the brunt of health inequalities; especially important at a time of austerity.

Adaptation, actualization, ends and means

Utopian visions of health, while aspirational and even inspirational, are ultimately unattainable. Humanity rarely, if ever, achieves stasis. People are constantly engaged in an often-problematic process of adaptation to their environments – to their physical, material, economic and social circumstances. The dynamic interaction between individuals and their environments is recognized in definitions of health promotion as enabling people to gain control over their lives and their health (WHO, 1984). Dubos’s (1979) influential perspective on health supposes that positive health is a mirage. As reiterated by Blaxter (2010) – health is evanescent and unattainable, but worth pursuing. If health means anything, it resides in the pursuit, in engaging with these constantly changing and typically unpredictable environmental forces.

Aspects of Maslow’s (1970) notion of self-actualization resonate with Dubos’s perspective on the nature of health. Maslow defines it as follows:

Self-actualization … refers to man’s desire for self-fulfilment, namely, to the tendency for him to become actualized in what he is potentially. This tendency might be phrased as the desire to become more and more what one idiosyncratically is, to become everything that one is capable of becoming … In other words, ‘What a man can be, he must be.’ (1970: 46)

Apart from providing a useful operational definition of psychological health and his emphasis on the importance of self-esteem, Maslow’s work has considerable relevance for the empowerment imperative of health promotion. Furthermore, it raises the issue of whether health is an end in itself – a terminal value – or whether it is instrumental for the achievement of other valued goals. The latter interpretation is encapsulated in the Ottawa Charter conceptualization of health as a ‘resource for everyday life, not the objective of living’ (WHO, 1986) and in the Declaration of Alma Ata (WHO, 1978) as a means of achieving a ‘socially and economically productive life’. Whether desired goals in this context are defined by individuals themselves or by society, generates further questions about the respective emphasis on self-actualization or collective responsibility.

Coherence, commitment and control: health as empowerment

In an article published posthumously, Antonovsky (1996) declared his concern about the dominant paradigm common to both medicine and health promotion. This, he argued, is based on the dichotomous classification of people into those who have succumbed to disease as a result of exposure to risk factors, and those who have not. He urged health promoters to move away from this obsession with risk factors and adopt a ‘salutogenic model’ that views health and disease as a continuum and focuses on the conditions leading to wellness.

‘Salutogenesis’ is a key concept that focuses on the ‘salutary’ – that is, health enhancing – rather than ‘pathogenic’ – that is, disease causing aspects of health. It incorporates Antonovsky’s main theory about the factors that determine the extent to which people become healthy and experience well-being. Central to this theory is the challenge posed by coping with ‘the inherent stressors of human existence’ (1996: 15) – encapsulated in the notion of ‘entropy’ that refers to the level of disorder within systems. At a psychological level, it refers to perceptions that disorder exists. People’s worlds may be more or less chaotic. Such ‘chaos’ is held to be undesirable, whether it exists in reality or only in people’s perceptions. The salutogenic approach is, therefore, designed to reduce entropy and perceptions of entropy and, in so doing, generate a sense of coherence, which it identifies as a central attribute of a healthy person.

Antonovsky defines coherence as:

a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected. (1979: 123)

The three main elements are comprehensibility, manageability and meaningfulness. These are concerned with how we make sense of the world around us and what we experience; how we feel about this and the extent to which we are able to manage or cope with the challenges of life (Sidell, 2010). Mittelmark and Bauer (2017: 7) note that salutogenesis has a more general meaning and ‘refers to a scholarly orientation focusing attention on the study of the origins of health, contra the origins of disease’. A body of work on salutogenesis and health promotion has emerged from Scandinavia. For example, Lindström and Eriksson (2005, 2009) take a salutogenic approach to creating healthy public policy. They also argue that a salutogenic approach could be a solution to contemporary public health challenges, particularly with regard to mental health promotion (Lindström and Eriksson, 2005). A review by Harrop et al. (2007) set out to establish the evidence around resilience, coping and salutogenesis. The authors concluded that:

Although the quality of the evidence base is considered weak in terms of traditional review methods … there was considerable consistency in findings with regard to identifying factors associated with positive outcomes. This evidence suggests individual, family, community and institutional factors all play a role in buffering some of the effects of disadvantage and facilitating ...