Chapter 9 Public health and health promotion
What is health?
Before considering ‘public health’ or ‘health promotion’ it is important to briefly consider definitions of health. Ask three people the meaning of ‘health’, and each may give a different answer. One may say, ‘It’s when you’re not ill’. Another may say, ‘It’s when you can get around and do what you have to do’. A third may suggest that it is when you feel good about yourself. Each of these views has been described in numerous research studies (Blaxter 1982, Cornwell 1984, Mayall 1986, Pearson 1991).
The second view can be described as the ‘functional’ model of health – often used in relation to people with disabilities or older people. Difficulties arise with this model in a society where the boundaries of everyday function and the technological supports available are changing rapidly, and where activists have strongly put the case for a ‘social’ model of disability, which makes clear that it is the product of society’s inability to adapt and respond to impairments, demonstrated in function (French 1993). An extension of this idea is the notion of ‘social health’ – an ability to fulfil social roles. This is in many ways the obverse of Parsons’ (1951) idea of the sick role, in which being ‘ill’ confers exemption, for a period, from social roles.
The third view suggests that how people feel about themselves is more important than impairment or a disease process. The World Health Organization (1946) in its constitution brought together these ideas when they stated that health was, ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. While this has been criticised as Utopian, it has the merit of integrating the three most common conceptualisations.
What is public health?
My personal vote for the key person behind the original public health movement is Edwin Chadwick. Chadwick’s Report on the sanitary condition of the labouring population of Great Britain (Chadwick 1965) was seminal. He was a civil servant who drew together the reports of a range of local informants to produce a hard-hitting analysis of the morbidity created by overcrowding, lack of sanitation, long working hours and lack of leisure space or opportunity. Presented to the House of Lords in 1842, this led to demands for change. From these emerged the first Public Health Act in 1848.
At the beginning, public health was driven by concerns about visible suffering and high death rates. In the modern context these are the concerns of the ‘Third’ world (two-thirds of the world). In India, for example, only around 40% of households have toilet facilities even today, despite extensive government investment programmes. Provision of access to clean water has been more successful, though work now needs to be done to prevent build-up of waste water, which attracts mosquitoes and undermines progress on malaria. Polio is still relatively common, though intensive community education programmes and national immunisation drives are beginning to pay off, with 70% of 1-year-olds fully immunised against polio (UNICEF 2003).
The NHS was born in 1948, with an underlying philosophy of equity in provision and entitlement to care, together with notions about providing cure/care for all, largely associated with a medical model of health. To some extent, public health lay outside this agenda, since many of those involved in its delivery – health visitors, school nurses, directors of public health – did not join the NHS, but remained within the local authority setting. At the same time, developments were occurring in ideas about behaviour and psychological theory. Skinner (1953) and other behaviourists were working on ideas about animals which would lead to new conceptualisations about human behaviour. Over the next few decades, Becker and colleagues (1974) were pulling together theories about people’s health beliefs and examining the reasons why people take up or stop behaving in ways that damage health. Social theory was also developing rapidly, with sociologists looking at the development of professions, the functioning of communities and at marginal groups (Whyte 1993), while social policy was being driven forward by people such as Richard Titmuss (1970).
However, changes in patterns of service delivery were slow. In 1974, the NHS took in community health services, and at the same time set in place structures in which professionals began to be consciously ‘managed’. Emphasis began to be placed on policies and protocols. Record systems were revised. The ‘nursing process’, a model originating in hospital settings and relating to the management of one or more problems, was widely promoted and taken up by many community practitioners; for example, in the form discussed by Clark (1986). In 1979, the political context changed. Margaret Thatcher came to power and over almost the next two decades proclaimed that there was ‘no such thing as society’. Clearly, public health work had to reinvent itself to respond to the mood of the day.
In fact, two paths emerged. One, most clearly seen in the 1992 Health of the nation document, took up the medical model and proceeded to look, in the main, at individuals’ behaviour, focusing on the responsibility of each individual to contribute to improving health targets, and the need to provide individuals with the ‘information to help make the right choices’ (Department of Health (DH) 1992, p. 22). Though there was a suggestion that other agencies might play a part in promoting the health of the public through the notion of ‘healthy alliances’, this idea was poorly developed, and little was done to follow it up, except to some extent in local authorities who picked up the idea of health-promoting schools. The other main deficit of policy at this time, again clearly seen in the Health of the nation document, was the failure to acknowledge poverty and socio-economic factors as significant in shaping people’s health experience. The second pathway followed the community development ideas, which had flourished a decade or more earl-ier, and built on a salutogenic model of health (Antonovsky 1996), in which the key to a healthy population is that it has the resources for health. While the first approach was dominant, becoming increasingly so in government thinking, many community development projects were also set up during this time. Though many were short-lived, for example, Strelley in Nottingham (Boyd et al 1993), some (such as Castlemilk near Glasgow and Meadowell on Tyneside) survived into the 21st century.
Public health in general remained locked into these models, though there were some pioneers who began to look at what was known as the ‘new’ public health (Ashton & Seymour 1988). This rests on a model that draws on the World Health Organization’s definition of health, acknowledging that health is a product of many factors, and that work to promote and maintain health requires a balance between individually focused work and work at the level of society. Like John Ashton, who was involved in the development of the Healthy Cities Initiative (Ashton et al 1986), Steve Watkins, Director of Public Health in Stockport, was a pioneer of this new way of looking at public health. Against the grain of policy at the time, he facilitated the establishment of an integrated public health service in Stockport, which offered community-based health development work, as well as large-scale intervention programmes (Watkins 1994, 1996).
By 1997, when a landslide victory unseated the Conservative government of 18 years, politicians had begun to acknowledge that the individualistic model alone was not sufficient, and that ‘health variations’ (inequalities in health) required attention at a more structural level. The new government set in place a range of initiatives, which demonstrated that promoting and maintaining the health of the public was now a central plank of the government’s policies. The new NHS: modern dependable (DH 1997) shifted commissioning towards a healthoriented model and more firmly into primary health care. Late in 1998, the Acheson Report on ‘inequalities in health’ (Acheson 1998) and the publication by the Home Office of a Green Paper called Supporting families (Home Office 1998) gave further momentum to the shift to a psychosocial model of health. In the closing year of the millennium, the White Paper Saving lives: our healthier nation (DH 1999) highlighted the importance of community development approaches and of looking at environments (school, work and community), as well as the management of disease processes. It made clear the potential contribution of midwives, health visitors and school nurses, among others, to achieving this, building on their work with families and communities. In 2004, Derek Wanless, a financier, completed a review of the issues involved in maximising the health of the population, highlighting the need to tackle old problems in new and more imaginative ways, and to act appropriately on emerging problems (Wanless 2004). Most recently, the government has published Choosing health: making healthy choices easier (DH 2004). This is concerned with ensuring informed choice for all and supporting individuals and communities in making healthy choices. It also emphasises the need for partnership working across the complex network which influences the health of individuals and communities: statutory and voluntary agencies, advertisers, manufacturing industry, retailers and the media.
Future directions for public health?
Where will public health work move in the future? In Western societies one of the most significant health issues of today is mental ill health. Stress-related con-ditions are one of the commonest reported causes of work-related sickness absence. Unemployment too is associated with reduced psychological wellbeing, and a greater incidence of self-harm, depression and anxiety. Around one in six people in England of working age experience mental ill health at any given time (DH 1999). In the wider world, there is a need to promote the human rights of people with mental health problems, particularly those who are subject to involuntary detention (Council of Europe 2000).
The future health of our population is grounded in the health of today’s children and young people. There has been increasing recognition, for example, in the National Service Framework for Children (DH and DfES 2004), that the social, economic and environmental contexts in which children grow up make a significant difference to their health experience. Policy has moved away from a focus on health screening and developmental reviews to programmes of support to children and their families, such as Sure Start, which are intended both to help to address the wider determinants of health and to reduce health inequalities. However, recent work (see for example Belsky et al 2006) suggests that programmes of this sort may be more effective for children and families with some economic and social resources than for those with few.
In the UK and Europe, public health work is likely to be influenced by the development of education about risk assessment and communication: a two-way process in which ‘expert’ and ‘lay’ perspectives interact and inform each other. ‘Whole systems’ interagency collaboration is increasingly recognised as a way to enable local people and others with a broad spectrum of expertise and resources for meeting health needs. As technology continues to develop, it seems likely too that work to promote the health of communities and populations will be enhanced by the integrated and interactive use of developing technologies in identifying and targeting health needs.
A major challenge for the delivery of a healthy population in the 21st century will be shortages and changes in the health care workforce. In the UK, demographic change is rapidly altering the workforce available to promote and maintain health. The traditional roles of health professionals in many areas of both primary and secondary care will need to change significantly over the next few years. Movement is already being seen in the development of accessible primary care facilities based in stores and supermarkets, the establishment of ‘health trainers’ to give local support and focused information on health, and the move to generic ‘children’s workers’ at the interface between health, education and social care. Such changes are likely to accelerate. As around one-fifth of health visitors and school health advisers retire in the next few years, there will be a significant increase in the workload of those who remain. This will require professionals who are educated to embrace new roles and work with health care assistants, children’s workers and health trainers who will be educated to take over more routine activity. In the wider world, there is a global shortage of around 4.3 million health workers (WHO 2006). Significant under-provision in the poorest areas of the world, for example, critically low provision of doctors, nurses and midwives in sub-Saharan Africa, will have a major impact on population health. Recent work by the Joint Learning Initiative has shown that countries where these professions represent fewer than 2.5 per 1000 population achieve less than 80% coverage of measles immunisation or of deliveries by skilled birth attendants, with consequent poor health outcomes. Action to improve health will require recruitment and training of many more health workers.
Promoting health
While the promotion of the health of the public is an intrinsic element of ‘public health’, it is often confused with other closely related concepts. The World Health Organization (1984) suggests that it may be defined as ‘the process of enabling people to increase control over, and to improve, their health’. The process of promoting health may be undertaken in a variety of ways. Most often people think of health promotion in terms of, firstly, health education and, secondly, prevention. Tannahill (1985) highlights a third, overlapping, component, which he calls health protection. Each of these elements is discussed below.
Health education
Health education can be defined as giving people information about living healthy lifestyles and the skills to understand and use this information. In the early part of the 20th century, before the development of social and psychological theory, manuals gave detailed instruction on healthy living, with little concern about how real people might put the instructions into practice in real contexts (Board of Education 1928). In the later part of the 20th century, through to the present day, educational theory has developed further. Health educators have become aware, for example, that different styles of presentation of information may be effective for different audiences. Ewles and Simnett (1985) describe five different approaches to health education, which are listed in Box 9.1.
