Researching Health Promotion

Stephen Platt, Jonathan Watson

• Publisher: Routledge
• Year: 2002
• ISBN:
  9781134607280
• Edition: 1
• Topic: Medicina
• Subtopic: Salute generale

Addresses key current debates in health promotion The result of the very successful 1st UK Health Promotion Research Conference

Chapter 1
Connecting policy and practice
The challenge for health promotion research

Jonathan Watson and Stephen Platt

Introduction

We are witnessing a number of significant political, economic and social transformations that are bringing about important changes in the conception and organisation of health and social care. The World Health Organization has for some years seen itself as addressing the ‘new social, political, economic and environmental challenges’ of the close of the century (WHO 1991). One consequence of these transformations has been the privileging of public health and the improvement or promotion of health. However, in this chapter, we argue that there has been little coherent attempt to align theoretical developments in health promotion research to shifting policy agendas.

Building on the Lalonde Report (Lalonde 1974), the Alma Ata Declaration on Primary Health Care (1978), and the Health For All 2000 Strategy (1981), the First International Health Promotion Conference in Ottawa in 1986 (WHO 1986) focused on the potential for widening the role of health promotion to encompass work with communities and organisations as well as with individuals. To accomplish this it identified five strategies for health promotion action: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorientating health services. More recently, the Fourth International Conference in Jakarta endorsed this approach and identified a number of key action points to carry the health promotion agenda forward into the twenty-first century:

• promoting social responsibility for health (i.e. private and public sectors should pursue policies and practices that avoid harm to health)
• increasing investments for health development (i.e. using a truly multi-sectoral approach and prioritising the needs of particular groups)
• consolidating and expanding partnerships for health (i.e. between the different sectors and at all levels of society)
• increasing community capacity and empowering the individual in matters of health (i.e. health promotion by and with people, not on or to people)
• securing an infrastructure for health promotion (in particular, through targeting settings such as schools and workplaces).

(WHO 1997)

The agenda established in Ottawa, and developed subsequently through conferences in Adelaide (healthy public policy), Sundsvall (supportive environments) and Jakarta (partnership), is mirrored in the UK by fresh Government initiatives on the future of the National Health Service (DoH 1997, SODoH 1997), new health policy (DoH 1999, SODoH 1999) and action on social inclusion (Social Exclusion Unit 1998, The Scottish Office 1999). Overall, the nineties have witnessed a radical shift in the policy agenda from a neo-liberal ideology, which targets the privatisation of health by devolving responsibility for managing risk to the individual (Petersen 1997:194), to the new public health agenda, which seeks to address the socio-economic determinants of health in addition to the existing lifestyle focus.

The evolving nature of health promotion has implications for health promotion research and related research agendas. By health promotion research, we mean research that services the needs of health promotion by, for example, helping to refine the practices and approaches of health promotion. Relevant questions include: what works, in what circumstances and with whom? (Health Education Board for Scotland 1999, Wimbush in press). By contrast, research on (or of) health promotion, may be concerned with developing critiques of health promotion practice or studying the values base of policy and practice (Nettleton and Bunton 1995:41–3, Thorogood 1992). These should not be discrete enterprises. Specifically, we need to be able to assess scientific knowledge relevant to health promotion across a variety of research paradigms/ disciplines; and decide when existing basic research in a particular area supports a transition to more applied research (health promotion research). Both encompass a wide range of disciplines, among them epidemiology, anthropology, psychology, organisational and political science and sociology, that do not always sit comfortably side by side.

This volume draws on papers presented at, and reflections prompted by, the First UK Health Promotion Research Conference, held in Edinburgh in April 1998. The conference was organised against the backdrop of this evolving international agenda and recent UK Government policy initiatives. As such, it provided a timely opportunity to explore the main challenges for health promotion research in the twenty-first century.

Two key themes recurred throughout the conference: the nature of knowledge and the meaning of evidence in health promotion. Epistemological debate on these themes is unavoidable, in part because the health promotion field is shaped by, and interacts with, complex phenomena and processes, and in part because there is a diversity of expertise informing research, policy and practice.

The nature of knowledge

The terrain for basic and applied health promotion research is broad, ranging from population-level prevention activity, through individuallevel interventions to action on the structural and cultural determinants of health. While recognising the multi-faceted nature of health, its production and maintenance, the tendency has been to assume that health promotion practice should encompass a similarly broad sweep. Whitelaw et al. (1997) have argued that this tendency is unhelpful because it masks tensions between competing paradigms and agendas. Specifically, they warn that ‘the creation of …“global” health promotion models could inhibit constructive debate around alternative perspectives on health’ (480). They conclude by noting that ‘permanent tensions’ exist that need not necessarily be resolved. They identify three initial areas for attention: professional and political matters, technical and methodological dilemmas, and research questions. The challenge for practitioners is how they manage these tensions in order to deliver action that addresses contemporaneous policy agendas (ibid.: 487–8). This chapter raises issues for consideration in respect of the focus and nature of research within which specific research questions require framing.

The shift in the policy agenda can be attributed to a range of influences that can be encapsulated under three headings: governance in late modernity, health inequalities and agency. These provide a set of ‘lenses’ through which the development of theoretical domains in health promotion research and practice might profitably be focused and developed. The notion of ‘theoretical domains’ was developed by Dean (1993) with respect to the problem of linking theory and methods in population health research. According to Dean, ‘theoretical domains may be thought of as developmental frameworks for elaborating causal processes to build bodies of knowledge in substantive areas’ (ibid.: 29). In this context, problem solving is concerned with the complexity of dynamic relationships among components of a domain rather than the ‘prediction of global truths’ or probable outcomes. Dean’s concept has an intuitive resonance for an emergent health promotion field, because it not only situates theory in real world contexts but it gives a role to methods in the building of theory (ibid.: 30–32). Elsewhere, Noack (1997) and Platt (1997) have identified that in many health intervention studies the underlying theoretical models are non-existent or poorly defined. Rather by default, health promotion continues to rely largely on models and theories of health behaviour originally published in the 1970s (Wallston et al. 1978, Bandura 1977, Ajzen and Fishbein 1977, Becker 1974, Bem 1972, Rogers and Shoemaker 1971). Overall, there has been little coherent attempt to align theoretical development to shifting policy agendas (notable exceptions include Gillies 1998, Gillies and McVey 1996, Whitelaw and Williams 1994; Ziglio—see Chapter 2). Similarly, the manifest good intentions of health promotion have acted as a barrier to the development of an informed critique (for exceptions see especially Seedhouse 1996 and Bunton et al. 1995).

Governance in late modernity

Giddens argues that we are living through a period of ‘late modernism’ characterised by rapid social change which profoundly ‘affects pre-existing social practices and behaviour’ (Giddens 1991:16; see also Giddens 1990). This is set against a context of broad social transformations of globalisation, the advent of new cyber and information technologies, the changing nature of the disease burden, ageing populations and the rise of consumer culture (Burrows et al. 1995, Featherstone and Burrows 1995, Featherstone 1991). These circumstances are said to give rise to chronic uncertainty and heightened notions of risk. In these circumstances, scientific knowledge is constructed around risk and the expertise required to manage risk (Petersen 1997, Beck 1992, Giddens 1991). However, as Lupton notes: ‘The risks which are selected by a society as requiring attention may…have no relation to “real” danger but are culturally identified as important’ (Lupton 1995:80). Critically, as Lupton later asserts, ‘the notion of internally imposed risk has yet to be fully critiqued for its political and moral dimension’ (ibid.: 81) and it is this perception of risk, derived from clinical medicine and epidemiology, which tend to inform health promotion.

Arguably, such developments in the policy agenda can be seen as opening up new opportunities for surveillance (Armstrong 1995, 1983). This perspective is informed by Foucault’s work (1979, 1973) which gave an impetus to the identification and examination of new forms of governance and concomitant techniques of surveillance (Watson in press, Petersen 1997, Lupton 1995, Armstrong 1995, Bunton 1992; see also Armstrong 1983 on epidemiology and general practice). However, the particular technique of surveillance of interest in this context is that of health economics. For, ironically, the boost given to health promotion by Ottawa and recognition of the key role of health promotion in Government health policy statements in the early nineties (DoH 1992, SOHHD 1992) coincided with global concerns about containing the escalating costs of health care (Macdonald 1996, Anderson 1984). Through a recognition that many health problems were related to individual lifestyles (Anderson 1984), the issue of cost containment became conflated with a concern to manage the consequences of risk. In this milieu, a key element of the new health care culture was that decisions about how to improve health and health care should be informed by evidence of need and especially evidence of effectiveness and cost-effectiveness. That is, given finite resources, choices have to be made between competing uses of health care resources. For example, a recent policy review summarised the cost-effectiveness of treatment and prevention of coronary heart disease. The authors concluded that ‘although not all forms of prevention are successful or represent value for money, there is evidence that well-designed and targeted programmes, particularly those concerned with smoking and diet, can have a significant effect on reducing risk factors, and represent good value for money in terms of life gained’ (SODoH 1996:65).

Although such assessments appear to make a prima facie case for health economics, there is debate regarding its value to health promotion (Craig and Walker 1996, Tolley et al. 1996, Burrows et al. 1995, Cohen 1994). Burrows et al. (1995:241) state that the organisation and delivery of health care is increasingly realised through the concept of ‘value for money’. Most interestingly, they develop an argument that the hegemony of health economics within health systems is explained by an organisational need for ‘ontological security’ that ‘the rhetoric of rationality’ provides in an era (late modern) of incessant change and disruption. Nevertheless, they conclude that health economics is unable to adequately cope with the task of evaluating health promotion. This is significant, in part, because it challenges us to pose the question ‘on whose terms is something effective’ and what are valid endpoints in health. Crucially, there is a need to consider the consequences of pursuing community health promotion. In particular, what are valid endpoints or outcomes of such activity? Certainly, the measurement of community-level change poses major methodological problems but, as Sheill and Hawe (1996) have argued, the key issue is the extent to which one believes that community-level change is adequately captured by adding up measures of cognitive or behavioural change across individuals. Valid endpoints for community health development programmes might include, for example, non-health or indirect health outcomes, such as sense of community, community empowerment, and community competencies that impact upon the social, cultural, economic, environmental and political determinants of health. It is imperative that the methods we use fully capture the desired effects of a programme. Fail...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Illustrations
• Contributors
• Acknowledgements
• Chapter 1: Connecting Policy and Practice: The Challenge for Health Promotion Research
• Part I: Fresh Thinking
• Part II: Methodological Challenges
• Part III: Good Practice