CHAPTER 2 Concepts and values in health promotion
Chapter 1 identified important principles in Primary Health Care and the New Public Health movement. The centrality of social justice and equity in the promotion of health and directly addressing the determinants of health problems were identified as fundamental principles for contemplation and action in public health. Definitions of health and health promotion were examined in the context of their historical development.
DEFINING HEALTH
Two notable efforts to define health of individuals within a broader socio-environmental context have come from the Aboriginal health movement and the environmental movement, where concern for spiritual and cultural connectedness and ecological sustainability, respectively, have moved health definitions beyond the individual, and so, for example, Aboriginal health has been defined as:
The values, attitudes and beliefs of health promotion
Attitudes
Attitudes are positive or negative feelings about certain things. Attitudes are something internal to a person but attitudes influence the way the person thinks about, feels about, or behaves in response to an issue or stimulus. Attitudes consist of cognitive, affective and motor aspects. The cognitive aspect means that we have personal understandings about that thing, such as smoking, violence or service to the community. A person’s attitude may be based on accurate or inaccurate information. The affective aspect means we are influenced in forming attitudes by our emotions or feelings, such as if we have had a personal experience of someone close to us suffering lung disease, or if we have been regularly verbally and socially abused, or have had a family tradition of volunteering for community organisations. The motor component relates to our tendency or likelihood to take action; or example, not smoking, taking assertiveness classes, or volunteering to work for a cause or something we believe in (Quinn 1988: 359). It is clear that our attitudes affect what we see and how we see it. Studies have shown there is a low correlation between attitudes and behaviour. Attitudes can also be powerfully influenced by external forces, such as media cues and images. Yet, attitudes are personal, and sometimes irrational. They may be based on unbalanced or inaccurate information. They are derived from the diverse cultural, family and social range of experiences that make up our individual lives. Attitudes can change and be changed over time, as a result of new learning or new experiences.
Beliefs
The likelihood that values, attitudes and beliefs can be changed as a result of a person receiving new or accurate information, developing an emotional commitment to making a change, or having a significant health experience or outcome, has been the basis of formulation of a number of behaviour-change models of health education, such as the Health Belief Model (Becker 1974) and the Transtheoretical Model (Stages of Change) (Petrushka & Di Clementi 1984). These models will be presented in more detail in Chapter 7.
Values underpinning practice
Values of health promotion practice may be implicit, implied in the common values and standards expected in society, such as respect for others, or they may be made explicit in the guiding principles of the health agency, perhaps set out in a professional code of practice, mission statement or other strategic planning documents. Expected professional values may also be made explicit in a formal contract that a worker enters into when they are employed, or in the ‘oath’ that professionals take when they are formally accepted into a professional role, such as the nurses’ codes of professional practice. Professional practice in health promotion implies that a health worker’s actions will be guided by the values set out in the philosophical frameworks that underpin their practice; primarily, the Declaration of Alma-Ata (see Appendix 1), but also, other complementary documents such as the Declaration of Human Rights (see Appendix 3) and the Earth Charter (see Appendix 4). Equity and social justice are key values that are common across these and other philosophical frameworks.
Attitudes, values and beliefs in action
Personal responsibility for health gain
Encouraging people to take responsibility for their own health, both individually and at the levels of the community and the country, is part of the Primary Health Care approach. The re-emergence of these ideas began with the Declaration of Alma-Ata’s call for action ‘in the spirit of self-reliance’ (see Appendix 1), and with the introduction of social marketing messages, designed to ‘sell’ the ideas of personal behaviour change for health maintenance. As the relationships between individual behaviours and illness were identified, calls for change in individual behaviours became more and more popular as an increasing number of diseases were labelled as ‘lifestyle’ diseases; the inference being that people ‘chose’ these behaviours as a part of their lifestyle, and thus it was a matter of individual choice for them to change to healthier behaviours.
Victim blaming
Individuals live their lives in a social context and there are many factors that influence an individual’s lifestyle. As the previous discussion points out, a great many of the determinants of health are the result of the social, economic and political structures in which people live their lives. There are some real dangers, therefore, in focusing only on the role of individual behaviours in disease causation and management. People may be blamed for ill health, and for some of the determinants of ill health, when they do not have control over the factors affecting their health or the freedom to make healthy choices. They may be unable to make changes in their personal health behaviours because of the social, environmental or cultural circumstances of their lives. Making judgments about those who are unable to change has become known as ‘blaming the victim’.
The influence of labelling
The use of ‘strengths perspectives’ (Wieck et al 1989, cited in Jimerson et al 2004: 9) is increasing in many disciplines including mental health (e.g. constructivist therapies), nursing (e.g. wellness vs illness), asset-based community assessments (which will be referred to in Chapter 6), and education research (e.g. resilience) (Jimerson et al 2004). Terminology such as ‘asset’ and ‘protective factors’ are used instead of ‘needs’ and ‘risk factors’. The identification of and building of strengths within individuals, families and communities describes positive relationships, competencies and opportunities, rather than a ‘deficits’ focus (Jimerson et al 2004: 9).
Dealing with opposing values and conflicts of interest
The extent to which people value their health depends on a wide range of factors in addition to the state of their bodies. However, the WHO definition of health has been criticised on a number of grounds (see, for example, Sax 1990; Naidoo & Wills 2000). On one hand, firstly, it has been argued that it is unrealistic and unachievable, because it describes a state of such total wellbeing that it is unlikely that anyone could achieve it for more than a very brief period in their lives. With its focus on perfection, too, it excludes those with disabilities or long-term medical conditions. Secondly, it has been criticised for being unmeasurable, describing, as it does, a general state of wellbeing. It has been pointed out that, despite health having been defined this way since 1948, health statistics still only enable us to measure death and disease and we remain without effective measures of health broadly defined (Mathers & Douglas 1998: 125). On the other hand, some have criticised the WHO definition for not being broad enough. For example, a number of authors have noted its lack of inclusion of spiritual wellbeing, which is increasingly being recognised as important (Teshuva et al 1997; Raeburn & Rootman 1998). And, as noted above, those in the Aboriginal health and environmental movements have criticised its definition of individual health out of a cultural and ecological context. Despite the criticisms that have been made of the WHO definition of health; that it is too broad and unmeasurable, or too narrow and lacking spiritual and ecological dimensions, it remains an important concept, and is an important starting point because it has pointed the way to consideration of the determinants of health (Naidoo & Wills 2000).
Defining wellbeing
1. Income and socioeconomic position. Important factors in explaining differences in wellbeing are not only access to material conditions, but also the social advantages attached to a particular social position.
2. Culture and kinship. For many people, the expression of shared identity, values, beliefs and language is an enabling and protective factor for their wellbeing. Cultural safely is an important health protective factor.
3. Education and training. Education enhances human capital — the capacity to participate successfully in the workforce, and the economic and social benefits derived from this.
4. Employment and working conditions. Employment provides opportunities for people to exercise control over their lives. Like income there are gradients of control and workplace safety which may enhance or inhibit wellbeing.
5. The physical environment. The safety, quality and sustainability of our physical environment provides the basic necessities for sustenance and pleasure for current and future generations.
6. Social support networks. The sense of connectedness and support provided by friends, families and communities are protective of health and wellbeing.
7. Early life factors. The early life experiences of a child, such as living in poverty, or living in an abusive family, set the path for cognitive and social success in later life.
8. Individual behaviours and lifestyle factors. Our personal behaviours and practices can promote or compromise health and wellbeing. However, many of these lifestyle behaviours reflect decisions that are socially patterned by people’s economic and social opportunities.
9. Access to effective human services. Equitable access to culturally appropriate high quality Primary Health Care services can be very effective in preventing or ameliorating many illnesses.
(Source: Adapted from South Australian Key Determinants of Health and Well-being Report 2004 Inequality in South Australia — Key Determinants of Wellbeing, Volume 1: The Evidence. http://www.publichealth.gov.au/publications/inequality-in-south-australia—key-determinants-of-wellbeing_-volume-1:-the-evidence.html)
Quality of life
having good social relationships
experiencing a sense of control over one’s life and one’s living conditions
being able to do things one enjoys
having a sense of purpose in life
There is growing recognition of the importance of quality of life in people’s experience of health, but judgments about factors such as these can only be made by the individual. This is significant firstly because it loses impact in the language of epidemiology, but secondly because it alerts us to the importance of enabling people to make the decisions about their own health and quality of life, rather than imposing judgments on them (Johnstone 1994: 391–7). There is also growing evidence that wellbeing and quality of life have a direct bearing on physical health (Marmot & Wilkinson 2006). Knowledge about the inextricable relationship between physical and mental health is growing all the time, but we still have a great deal to learn in this area.
EQUITY, EQUALITY AND SOCIAL JUSTICE
Equity
Thus, social health policies designed to ensure equity of access become a means of achieving equality. Many strategies to enhance equitable access to health services are outside the domain of the health sector. These can include strategies to redistribute wealth through the taxation system or a universal health insurance system. They relate to activities in transport, housing, sanitation, water supply and education. Equity also means consideration of the needs of future inhabitants of our communities.
Equality
Equity, equality and social justice are fundamental values that underpin health promotion practice. Putting these values into practice means working to reduce the systematic disparities in society by providing opportunities for disadvantaged groups to take control over aspects of their lives that would improve their health. Jeanne Daly’s story of the structural and social factors influencing the lives of passengers aboard the Titanic, presented in Insight 2.1, provides a classic example of how such factors can be largely outside the control of people who are affected most.
INSIGHT 2.1 Challenges in public-health promotion: a way forward
The White Star Royal Mail Triple-Screw Steamer Titanic was the biggest ship of its time, the acme of industrial progress, designed to capture the trans-Atlantic trade from the Cunard shipping company. The ‘Queen of the Ocean’ was advertised as the ultimate in luxury and its maiden voyage was expected to draw on board some of the richest people of the time. In the boardroom of the White Star line the decision was taken to increase the space for the first class promenade by reducing the number of lifeboats installed on the top deck.
On its maiden voyage the ship sailed from Southampton, stopped at Cherbourg, and made its last port of call in Ireland at Queenstown. As the ship sailed away, Eugene Daly (no relation) took his Irish bagpipes to the third class promenade and played ‘Erin’s Lament’. Despite the advertised glamour, this was an emigrant ship. In steerage (third class) were 706 people, many from the Balkans, Scandinavia, The Netherlands, England and Ireland, going to seek a new life in the New World. It was the fares of these third class passengers that helped justify the building of the luxury liners. There were an estimated 325 people travelling in first class and 285 in second class.
Life on the ship was strictly segregated, reflecting the class divisions of the time. First class passengers had the upper decks. Here the Astors, the Guggenheims and other wealthy American industrialists promenaded and socialised. Corseted women sat on deck chairs while children played. The men struck business deals in the all-male smoking room, sending messages to their companies on the revolutionary new wireless system. First class meals were served in grand dining rooms. Their day started with the enormous breakfasts that characterised the excesses of the Edwardian era. The dinner menu boasted 11 rich courses. A different wine was served with each course. This was not a healthy lifestyle.
A descent into the bowels of the liner was also a descent on the social ladder. Let us skip over second class and go to third class, the passengers travelling on the lowest decks. Here the dining room was a lot less plush, but comfortable. Dinner, served at midday, was a sensible meal of meat, vegetables and pudding or fruit. There was no alcohol served at meal times, but there was a public bar. In the general room there was a piano, and on the deck outside was a small promenade. Except for the limited space for exercise, we would find little fault with this much healthier lifestyle.
The internal structure of the liner set in place the rigid segregation of the three classes. They ate and exercised on separate decks, even had their hair cut by different barbers. Passageways connected first and third class, but these were hidden, used mainly by staff to traverse the ship without being seen by passengers. There was no lifeboat drill, so third class passengers were never shown how to negotiate their way to first class and the lifeboats. If there was conflict between the classes, it was structurally contained by geographic separation. Passengers saw only their own section of the ship.
Despite the unhealthy lifestyle of the first class passengers, on the Titanic, as in life, third class passengers had higher mortality rates (Table 1) [not reproduced]. The mortality rate for cooks was 94%. On the Titanic, as in life, it was healthier to eat first class meals than to cook them.
But, of course, the problem was not the meals eaten or the smoking and drinking, but a structural lack of opportunity. When the ship hit the iceberg and sank, there were only lifeboats for half the people on board. Women and children were to be saved first. Third class passengers were trapped below decks, although some managed to negotiate the labyrinthine passages to the top deck. There are accounts of crew making way for women and children by hauling from the lifeboats ‘swarthy’ men from third class who were hiding under the blankets. So intent were they on this task that some lifeboats were not filled.
On the deck, as the ship went down, a priest heard confession from those remaining on board. The band played on — according to some survivors they were playing the hymn, ‘Nearer, My God, to Thee’ — until they were swept away as the ship went down. Perhaps the third class passengers also sang ‘Nearer, My God, to Thee’ around the piano in the general room as the freezing water rose around their feet.
The Titanic’s mortality statistics tell a stark story of inequality. While 62% of first class passengers were saved, 62% of third class passengers drowned. While all children in first and second class were saved, 65% of those in third class drowned. While 54% of third class women went down with the ship, 33% of first class men were saved. Included in the first class men who survived was Sir Cosmo Duff Gordon. He was later accused of bribing the crew in his half-empty lifeboat to row away from the ship, ignoring the desperate cries of survivors trying to cling to anything that would save them from the freezing water. Also saved was J. Bruce Ismay, chief executive of the White Star line. When he went on board the Carpathia, the ship that rescued the survivors, he sent a wireless message to New York to stop the wages of all crew rescued from the time the ship sank.
The disaster threw into stark detail social inequalities that usually remain hidden. The interpretation of these statistics gives rise to a rich variety of understandings. Early reports glorified the heroic behaviour of the ‘kings of finance, captains of industry’ who stood aside to save ‘some sabot-shod, shawl-enshrouded, illiterate and penniless peasant woman from Europe’. Why struggle for greater social equality, the rhetoric went: all that it would achieve would be to replace these glorious Anglo-Saxon heroes with the ‘frenzied mob of armed brutes’ (the ‘foreigners’ from third class) who had to be kept out of the lifeboats at gunpoint.
This version of events found its echo in the inquiry into the sinking. The inquiry found that third class passengers were partly responsible for their own deaths. They were reluctant to leave the ship, unwilling to part with their baggage, or unable to speak English. There was a lesson, too, for women supporting the growing Suffragette Movement: equality would mean an end to preferential access to lifeboats. Images of rich and poor men dying together to save their women thus provided reassuring images of an harmonious social consensus that denied class and gender inequality but that emphasised the threat to it from the undisciplined brutes in third class.
These conservative images faded under the combined criticism of other interpretations of the event. Ben Tillett, of the Dock, Wharf, Riverside and General Workers’ Union, railed against ‘the vicious class antagonism shown in the practical forbidding of the saving of the lives of the third class passengers’. The New York Evening Journal of 16 April 1912 published an editorial on:
The crew on the Olympic, sister ship to the Titanic, went on strike for safer working conditions pointing out that they would be in an unenviable situation in the event of a sinking, ‘even if accompanied by the band playing “Nearer, My God, to Thee”. Women’s unions pointed out that, far from benefiting from the system, ‘the lives and health of thousands of women and children are sacrificed continually through their exploitation in mills, workshops and factories’.
The result was that shipping regulations were changed to make it compulsory to have a seat in a lifeboat for every passenger. Although the inquiry into the sinking failed to identify any villains on the Titanic, history, and Hollywood, have pilloried the owners of the White Star shipping line. Even at the time, J. Bruce Ismay became popularly known as J. Brute Ismay. He retired from public life.
(Source: Health Promotion Journal of Australia 2000, 10(1), April, footnotes deleted)
Social justice
The evidence of the impact of inequality on both individual health and the health and wellbeing of societies serves to highlight the importance of social justice on both the experience of individuals living in a society and the health and success of society as a whole. Glyn and Miliband (1994) identified that inequality affects more than the health of the population — it also affects the economic health of a society. Drawing together a wide range of research, they argued that social justice is actually good for a country’s economy, and that inequalities in a society have detrimental effects on a country’s economic growth. This evidence serves to highlight and reconfirm the importance of the Primary Health Care approach.
Health care expenditure and health status
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