Health Promotion

Disciplines and Diversity

Robin Bunton, Gordon MacDonald, Gordon Macdonald, Robin Bunton, Gordon MacDonald, Gordon Macdonald

• Verlag: Routledge
• Jahr: 2003
• ISBN:
  9781134563531
• Auflage: 2
• Thema: Medicine
• Thema: Public Health, Administration & Care

Health promotion is an increasingly central tenet in health professionals' lives. It has come into the public eye as the subject of party politics and policy, but where does the movement come from?
This book brings together views from a range of subjects, some not always associated with health promotion, such as marketing or communication theory. Others, such as social policy of psychology may have obvious connections to make; here the implications for practice are discussed fully for the first time. The volume adds up to a timely reflection on the state of health promotion today and will provide practitioners and academics alike with a clearer undersanding of a discipline at the frontier of contemporary policy and practice.

1 Health promotion: disciplinary developments

Gordon Macdonald and Robin Bunton

Health promotion emerged in the 1990s as a unifying concept which brought together a number of separate, even disparate, fields of study and has become an essential part of the contemporary public health. Regarded by some as the delivery vehicle or mechanism for public health, health promotion now forms an important part of the health services of most industrially developed countries and is the subject of a growing number of professional training courses and academic activities. The implications of this growth have concerned many of those involved in health and health care delivery. Some of the initial momentum for its development sprang from dissatisfaction with what was typified as the bio-medical model of health associated with focus on disease, aetiology, and clinical diagnosis. More recently, health promotion appears to be addressing the mainstream health care issues of the twenty-first century by contributing to newer approaches to health improvement, whole population programmes, health impact assessment, investment for health projects, capacity building, community planning and involvement, and perhaps most importantly, evidence-based practice. Less effort has been made, however, in considering the nature of this new form of knowledge and practice, its salient features and the likely constraints on, and possibilities for, its development. Such reflection continues to be useful for facilitating and development in the field.

This chapter is concerned with the rapid development of discourse on health promotion as a field of study and practice. It asks whether or not health promotion can legitimately be thought of as a discipline and whether we can make sense of recent changes and conceptual ferment in terms of its emergence as a discipline. Though we argue that this question is far from answered, we suggest that recent changes in the knowledge base and the practice of health promotion are characteristic of paradigmatic and disciplinary development. The process and direction of development may not always be clear. Like the development of other bodies of knowledge, it can be complex and subtle. What is clear is that a broader range of theory is being drawn into the health promotion arena and new alliances of theoretical approaches are being made. Different theories are being drawn upon in a variety of different practical orientations to produce a more varied practice. The knowledge base of health promotion would appear to be growing more multi-disciplinary, as the professional background of health promoters is becoming more varied. We might then conceive of this diversity and change as disciplinary and/or multidisciplinary development. Before considering this, it is valuable to review the nature of health promotion, its history, and how it relates to health education and public health.

What is health promotion?

Stated simply, health promotion is a strategy for promoting the health of whole populations. This is true whether one adopts a structuralist or individual approach. Most definitions of health promotion (Tones 1983; WHO 1984; Tannahill 1985; Kickbusch 1997; Bracht 1999; Griffiths and Hunter 1999) accept that both individual (lifestyle) and structural (fiscal/ ecological) elements play critical parts in any health promotion strategy. These two elements in health promotion can be divided into a number of subordinate themes. Lifestyle approaches are concerned with the identification and subsequent reduction of behavioural risk factors associated with morbidity and/or premature death. A number of the themes within it can be grouped around the idea of education in its broadest sense. Education involves the transfer of knowledge and skills from the educator to the student or learner. Knowledge improvement and attitude shift (cognitive and conative changes), health skills (behavioural changes), and the development of self-esteem are all constituent parts of these educational sub-themes. School health education curricula, stop-smoking clinics, and assertiveness training are all examples where these three educational methodologies are used in a lifestyle approach to health promotion.

Structuralist approaches to promoting health which focus on macro-social and political processes can also be divided into several sub-themes. These often centre around fiscal and legislative measures aimed at building healthy public policies, such as alcohol and cigarette taxation policies; progressive taxation policy to reduce inequalities in health, transport and agricultural policies; and ecological or environmental measures, such as waste disposal policies and urban planning. Health protection measures such as screening and immunization programmes lie between the lifestyle approach and the structuralist approach, since both service provision and behaviour change are involved. Community approaches to health promotion may, similarly, be placed between lifestyle and structuralist approaches. Health promotion is concerned then with two principal themes and a number of subordinate themes, all ultimately directed at reducing ill health and premature death.

Although having common themes, and with perhaps signs of conceptual convergence (Anderson 1984), conventional definitions of health promotion seem likely to continue to be characterized by diversity. Definitions of health promotion, like health itself, are subject to social and political influence and are, therefore, likely to vary across organizations and social contexts, making universal definition almost impossible. It might be preferable to allow a certain elasticity of definition such that each approach makes explicit its assumptions and distinguishes itself from its competitors (Simpson and Issaak 1982). Different definitions can represent different options or types of health promotion available to the health promoter according to the task or programme in hand, reflecting the variety of health promotion goals, target populations, as well as the focus and type of intervention (Rootman 1985; Raeburn and Rootman 1998). In this volume different versions of health promotion are assumed to be representative of current, and probably continued diversity in the field, rather than any inherent flaw. We feel it inappropriate in such a volume as this to attempt definitive definition. Any eventual consensus on such matters will be the outcome of developments within the field and the allied disciplines we draw together here. Attempts at definitive definition are likely to anticipate the outcome of this disciplinary process or knowledge system development, which is something we wish to avoid.

Health promotion and public health

Health promotion did not grow in a vacuum but developed largely out of health education and in tandem with the development of the ‘new public health’ movement of the late twentieth century. We are not concerned here with a strict chronological development of health education since that is covered more than adequately elsewhere (e.g. Sutherland 1979). Our focus is the evolution of health promotion, and the ways in which theory has emerged and interacted with practice. We refer to the different ways scientific knowledge and disciplines are developed, and relate these to recent shifts in theoretical reasoning underpinning public health debate. In order to find the conceptual roots of health promotion, we must look to the roots of public health more generally.

Dating the origins of public health is difficult, as specifying health domains by place – ‘public’ and ‘personal’ or ‘private’ – is a fairly recent preoccupation relating to the last 300 years or so of the rise of modern bio-medicine. Early systems of medical thought, such as those codified by Galen, linked health to the flows of humours and were closely tied to the public realm, including the movement of forces of the seasons and the universe in general. It is difficult to place notions of personal or ‘private’ health within such systems of thought. Movement of the cosmos was directly related to our ‘internal’ health and was deemed integral to the substance of our ‘individual’ bodies. There are, however, some precursors in early Greek and Roman thought to the distinctions now routinely made between public and personal health. For example, Hippocratic notions of endemic (always present diseases) and ‘epidemic’ (occasional and excessive disease) qualities are direct ancestors of the concepts used in contemporary public health and epidemiology (Porter 1998); indeed, such ideas were drawn upon in the first attempts to deal systematically with the plague. In ancient times and throughout the Middle Ages in Europe, isolation was deemed an appropriate way to regulate diseases that were seen to spread through contact. The use of the cordon sanitaire in seventeenth-century Europe, and much older lazaretto or ‘pest house’, became an institutionalized strategy which foreshadowed later developments in the government of health and interventions in the health of populations. The newer preventative methods of sanitation and immobilization for use in public health fit within the development of the new discourse of the Enlightenment and liberalism (Porter 1998). Contemporary concepts of public health would appear to owe much to the early modern period.

Whilst most commentators date modern public health by the first UK Public Health Act of 1848, they would also acknowledge developments in Germany and France at that time. Moreover, the early development of the field was associated with the health problems of newly industrialized cities in Northern Europe much earlier. Health in the public sphere can be related to the idea of ‘social medicine’, which has been closely tied to the development of greater state intervention under the doctrine of mercantilism. The early history of public health is linked to the ideas of social medicine, health administration, medical policing (Medizinalplizie), and social reform (Rosen 1958). More recent attempts at definition have tried to account for public health as a field of knowledge. Frenk (1993) argues that the discipline (or field of study) has constructed two major objects of analysis: the epidemiological study of the health conditions of populations, and the study of the organized social responses to these conditions. These foci correspond to two main currents of thought with their roots in the worship of Hygeia and Aesculapius (Dubos 1959). They also provide taxonomy with an analytical focus, which allows us to subdivide health research into bio-medical research (sub-individual level), clinical research (the individual level), and public health research (the population level).

Modern public health legislation in the UK emerged in the aftermath of the Poor Law Amendment Act of 1834. Edwin Chadwick was appointed to administer the new scheme and soon became aware that there was a relationship between poverty and ill health. Sickness and ill health were largely the result of bad sanitation at home (and work) and filth and poor ventilation at work. As a result, Chadwick propounded his ‘sanitary idea’, which was in effect the beginning of a national public health service, and gave rise to the first Public Health Act in 1848. John Simon took up Chadwick’s ideas and as the first full-time salaried medical officer of health, he was instrumental in getting the second Public Health Act passed in 1872; this created local medical officers of health and led essentially to the medicalization of the public health movement. Although initially these doctors had a broad remit that included sanitation and housing, increasingly through the last quarter of the nineteenth century and the first quarter of the twentieth, their focus began to narrow as a technologically focused, hospital base gained ascendency. The work of the Central Council for Health Education, founded in 1927, was the education arm of a service that primarily dealt with illness and disease.

Public health went through periodic reorganization in the twentieth century. Whereas nineteenth-century public health directed interventions, in the main, at environmental infrastructures that affected health, by the early twentieth century the focus had begun to shift towards individual health, with the development of comprehensive vaccination and immunization programmes. Changing social conditions at that time, as Turner has observed (1992, 1995), supported the growth of hospital-centred, specialist medicine, based upon an individually focused, fee-for-service, largely led by a growing middleclass demand for health care. This emergent health care challenged the social interventionism preferred by ‘social medicine’ of the turn of the twentieth century. A belief in technological progress was implicit in this period, following several major technological advances in science and medicine and improvements in surgery, drug treatments, and hospital procedures. Anaesthesia and germ theory were making advances, as were antiseptic procedures based on the work of Lister and Pasteur. Th...

Inhaltsverzeichnis

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Foreword
• Contributors
• Acknowledgements
• Introduction
• 1 Health promotion: disciplinary developments
• Part I Primary disciplines
• 2 Psychology and health promotion
• 3 What is the relevance of sociology for health promotion?
• 4 Epidemiology and health promotion A common understanding
• 5 The contribution of education to health promotion
• Part II Secondary disciplines
• 6 Health promotion as social policy
• 7 Health promotion and politics
• 8 Using economics in health promotion
• 9 Communication theory and health promotion
• 10 Social marketing and health promotion
• Part III Reflections and developments
• 11 Health promotion theory and its rational reconstruction Lessons from the philosophy of science
• 12 Introducing ethics to health promotion
• 13 The new genetics and health promotion
• Glossary
• Index