Chapter One. Theory into practice
• Relationship between public health and health promotion
• Professional roles
• Process and principles
• Skills for public health and health promotion practice
• Theoretical frameworks
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An understanding of the public health and health promotion theory is essential to informed practice. Yet identifying that body of theory is difficult and applying theory to practice is not straightforward. Many occupational groups claim a role in promoting health. Yet each may draw upon a different knowledge base (e.g. biomedicine, education, psychology, social sciences, organizational development) and have a different perspective on what constitutes public health and health promotion. The improvement of health and well-being may appear to be unproblematic and self-evidently a ‘good thing’ but it allows for a wide range of actions from efforts to change individual lifestyles, educational work with young people, to actions that change social structures. This chapter argues that practitioners should be aware of the values implicit in the approach they adopt. In so doing, practitioners begin to clarify their view of the purpose of public health and health promotion and the strategies that are suggested by different aims. Otherwise practitioners merely respond to practice imperatives and their work is limited to narrow tasks.
Public health is what we, as a society, do to assure the conditions for people to be healthy.
Committee for the Study of the Future of Public Health Washington 1988.
From the seventeenth to nineteenth centuries, public health was preoccupied with eliminating diseases such as bubonic plague, smallpox and cholera. With industrialization and rapid urbanization in the nineteenth century, public health work became focused on environmental issues such as clean water supplies, disposal of waste, and better housing, which were the province of engineers and planners. In 1842, Chadwick wrote in the Report on the Sanitary Condition of the Labouring Population of Great Britain that to prevent cholera ‘aid must be sought from the civil engineer, not from the physician who has done his work when he has pointed out the diseases that result from the neglect of proper administrative measures, and he has alleviated the suffering of the victim’.
The epidemiological transition during the twentieth century saw the main causes of death and disability shift from infections to chronic illnesses such as heart disease, stroke, cancers, respiratory illness and accidents, where lifestyles play a causative role. Public health interventions included mass screening and vaccination and immunization programmes as well as education and advice delivered by practitioners and mass media campaigns. Public health in England can thus be divided into two periods – the Sanitary Reform period when improvements were sought through a better physical environment and the Personal Services period when the emphasis was on personal health and hygiene.
In more recent times, the political agenda in most of the Western world has been dominated by ‘social responsibility’ and a recognition of the importance of the wider (upstream) determinants of health. Promoting health is now recognized as a multi-agency task. Since health and well-being are affected by so many factors, health improvement cannot be delivered by the health service alone, but will arise from cross-sector action on the environmental, economic and social determinants of health such as low income, housing, transport, food supply, crime and disorder, and employment.
This chapter will explore some of the complexities involved in translating modern public health into a multidisciplinary and multiprofessional area of practice. It will examine:
• the scope of modern public health and current terminology
• the relationship of public health and health promotion
• the skills and competences of a multidisciplinary public health specialist/practitioner
• the process of modern public health
• the values and principles underpinning public health.
The scope of modern public health
What is understood to be encompassed by public health will depend on conceptualizations of health and the influences upon health and well-being, the consequent purpose and goals of improving the public’s health, its scope of activities and who will be part of the associated workforce, and the values and ways of working that will underpin those activities.
Actions to improve health take different forms. If the reduction or absence of disease is the principal aim, health improvement centres around preventative medicine and influencing or persuading people to adopt healthier lifestyles. Health may be viewed more broadly as a way in which people can begin to achieve their potential; health improvement then centres around community development and involvement. Health may be seen as socially determined and a fundamental right; health improvement then centres on addressing the root causes of ill health in the physical, social and economic environment through developing integrated health strategies tackling areas such as housing, employment and nutrition.
The purpose of modern public health is to protect and promote health by:
• improving people’s life circumstances (e.g. housing, employment, education, environment)
• improving people’s lifestyles
• improving health services
• protecting the public from communicable diseases and environmental hazards
• developing the capacity of individuals and communities to protect their health.
The objectives of the national strategy to tackle obesity (DH 2008) illustrate the potential range of activities with which a practitioner might be involved:
• Promoting healthy growth and healthy weight in children, for example maintaining breastfeeding.
• Promoting healthier food choices, for example provision of food in schools and nurseries.
• Building physical activity into our lives, for example school travel plans and safer routes to school.
• Creating incentives for better health, for example point of decision educational materials and workplace cycle schemes.
• Personalized support for obese individuals, for example weight management in primary care.
I think we have a problem with the word health, because I think health has a certain set of definitions that are attached to it. And if you ask people what would make them healthier, or what would lead to better health, what they will tell you is that we need a lot more of the NHS-type health services. So people will quite genuinely tell you ‘if there were more doctors people would be healthier’.
Health is understood in many different ways but for most people it is associated with physical health. Although health is influenced by genetics, socio-economic circumstances and individual lifestyles, technical medicine, surgery and biochemical treatments receive most attention. McKeown’s analysis of the historical record of medicine (McKeown 1976) has had an enduring professional and political impact in puncturing medicine’s claims to importance in saving lives. The public, however, associate improvements in health not with environmental or economic change but with more medicine.
An increasing range of practitioners are likely to see public health goals and targets as part of their official remit. Local strategic implementation for obesity is likely to involve dieticians, teachers, school nurses, midwives, health visitors and sports development workers. Some of these (e.g. planners whose decisions regarding open spaces may influence people’s walking habits) would not normally conceive of public health as part of their role.
The key elements of modern public health are seen to be:
• having a population perspective
• recognizing the role of governments in tackling underlying socio-economic causes of ill health
• working in partnership with local communities to ensure their involvement in all stages of service development and planning
• working in partnerships with other agencies and the public to develop health improvement strategies
• developing the capacity of communities, professionals and organizations to work in this way.
The relationship between public health and health promotion
If public health is ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society’ (Acheson 1988), then health promotion would appear to be subsumed under public health. Traditionally, however, public health has meant disease prevention, an approach demanding knowledge of medical conditions and an ability to assess and monitor disease trends. In many Western countries, therefore, public health has been a specialty of medicine. More recently, the term ‘New Public Health’ has been used to reflect a broader, social view of public health.
Health promotion was defined in the Ottawa Charter (WHO 1986) as being centrally concerned with empowering people to take greater control over their health and thus includes a range of strategies to strengthen communities, develop supportive environments and inform and educate about health issues. In many countries health promotion is well established as a field of study and area of activity with a clear ideology deriving from the World Health Organization’s principles of 1984 (WHO 1984).
It is apparent that public health and health promotion are very different disciplines drawing on different bodies of theory, strategies and values:
The public health and health promotion professions embody – and tolerate – conflicting ideas of why and how health should and could be improved. The meaning of public health and health promotion are themselves contested and open to misunderstandings. The origins of these conflicts lie in the contested nature of health itself, of the causes of ill health, of the methods for reducing health and promoting well-being and fundamentally, in the motivation for such interventions.
Partly because of the diversity of its practice and partly because of the dominance of medicine as a profession and discipline, the robustness of health promotion in the UK has been questioned (Wills J, Scott Samuel, 2007 and Wills et al., 2008). The term health promotion has been largely replaced by the term ‘health improvement’, one of three domains of public health alongside health protection and service improvement shown in Figure 1.1 and identified by the Faculty of Public Health (Griffiths et al 2005). Debates over appropriate terminology reflect intense differences over purpose and scope. In Canada for example, ‘population health’ is now the dominant discourse replacing health promotion, which like public health in England privileges an epidemiological approach to understanding. This positivist model of research and inquiry results in the de-politicization of health issues.
What do you identify as the difference between public health and health promotion?
|Figure 1.1 • |
(Source: Griffiths et al 2005)
Your answer may have focused on the different scope of the activities, the different values and perceived purpose, or the different knowledge and skills required. Table 1.1 highlights some of the differences between health promotion and public health medicine.
|Public health medicine||Health promotion|
|Focus||Disease prevention, monitoring and management||Protection and promotion of health|
Sociology, social policy, education and psychology
|Core tasks||Research into the aetiology, incidence and prevalence of diseases|
Surveillance and assessment of population health
Managing outbreaks of communicable disease (and non-biological hazards)
Planning, monitoring and evaluating screening and immunization programmes
Planning programmes and services to improve healthcare provision
|Developing policies to protect and promote health in different settings|
Education and information for health and behaviour change
Working with communities to identify and meet needs
|Areas of practice||Health sector||All sectors where people ‘work, live and play’|
|Process||Top down: collecting information and policy development||Bottom up: collaboration and partnerships, capacity building of communities and individuals|
|Values||Authority, expertise, adherence||Collaboration, partnership, advocacy, mediation, enablement|
Modern public health therefore incorporates many of the activities, strategies and principles of health promotion. The disciplines underpinning public health and health promotion have different philosophies and forms of enquiry that inform different kinds of interventions to promote health, and disciplinary battles continue to rage over the relative contribution of biomedicine, epidemiology and the social sciences to our understanding of ill health. In the UK, the term multidisciplinary public health has become a widely accepted term to describe the range of professions and fields that will make up the public health and health improvement field and to overcome the distinction between medically qualified public health specialists and the non-medically qualified. The challenge for modern public health then is to move beyond public health medicine and to acknowledge the role of health promotion in the overall task of health improvement.
The public health workforce
Many countries are focused on the task of clarifying the nature of the public health function, the structure of the workforce and the building of its capacity and capability, and the consequent development of appropriate competences. Promoting health has become ‘everybody’s business’. The Chief Medical Officer of England (DH 2001) distinguished:
• those who lead and influence public health strategy (specialists), for example directors of public health
• those whose work contributes directly to health improvement (practitioners), for example public health nurses and midwives
• those whose practice should be informed by health improvement principles, for example social workers and teachers.
Many practitioners now have public health or health promotion identified as an aspect of their role and Chapter 10 in our first book Foundations for Health Promotion (Naidoo and Wills 2009) reviews some of these changing roles. There is also a body of professionals who are deemed ‘specialists’ by virtue of their training, functions and experience. For the past 50 years in the UK, specialist public health practice was the province of doctors who chose this medical specialty although this is now open to those who are not medically qualified. Health promotion was a clearly defined function within the NHS and open to people from diverse backgrounds but this specialized workforce has been eroded due to organizational changes (DH/Welsh Assembly 2005). Many professional groups have integrated health promotion into their practice and there are numerous studies exploring attitudes to the integration of health promotion into professional roles (e.g. Long et al., 2001, Maidwell, 1996 and McKay, 2008). It has been claimed enthusiastically, particularly by nurses in moves away from a single practitioner-single patient approach to one of greater partnership with clients and more work in and with communities. Yet this shift in focus has not been easy to put into practice.
Why might it be difficult for nurses to adopt a health promotion/public health role?
For most practitioners, such activities are additional to their primary role which is individual client care and disease prevention activities. Inclusion of community-based activities or education work into a practitioner’s remit poses an additional burden of work and extra time, resulting in it becoming ‘bolted on’ rather than integral to their way of working. Many health visitors, for example, struggle to release time from caseload work and routine assessment to focus on community-based activities. It is not surprising then that in most studies nurses frequently regard communication skills and the quality of the nurse-patient relationship as their most significant contribution to health promotion. The nursing process itself still encourages nurses to identify individual problems and therefore the ability to understand health as an interrelationship between social and political factors as well as biomedical and psychological factors is rare.
How do you think your professional group interprets its health promotion and public health role?
How practitioners interpret their health improvement role will depend on many factors including their professional training, their role in the organization, their personal experience, interests, and social and political perspective. Environmental Health Officers (EHOs), for example, work directly within communities and as such seem ideally placed to lead local government in its role to promote health. In practice, the spectrum of activity for EHOs is limited by their statutory duties under the Environmental Protection Act 1990 which enables action to be enforced where there is risk of disease. Work pressures and statutory duties mean EHOs spend their time on population protection and enforcement work and do not have the available time or resources to work proactively with communities. The examples of nurses and EHOs demonstrate how difficult it is to prioritize public health, even though practitioners may be very positive about their role and potential. By making public health everybody’s business, there is a danger that it becomes nobody’s responsibility.
Skills and competences for public health and health promotion
As we have seen, an increasing range of practitioners see themselves as promoting health. This raises the question of identifying recommended skills in order to undertake the task.
Consider the task of health improvement. What do multidisciplinary public health practitioners need to be able to do?
Many occupations including health promotion and multidisciplinary public health try to characterize their professional activity in terms of competences or standards for practice. In the UK, standards for public health specialists and practitioners have been developed (see Box 1.6) that relate to key functions and the competences that need to be evidenced to show achievement and in order to achieve registration to practise (currently as a specialist but practitioner registration is soon to be started). For example, to demonstrate competence in surveillance and assessment of population health, a specialist would need to have undertaken needs assessments using appropriate epidemiological and/or other approaches (see www.skillsforhealth.org.uk). Core skills in which public health specialists additionally need to demonstrate competence are strategic leadership, research and development, and ethical management.
• Surveillance and assessment of the population’s health and well-being, for example undertaking needs assessments and analysing routinely collected data
• Promoting and protecting the population’s health and well-being, for example investigating disease outbreaks, monitoring and controlling communicable disease outbreaks, monitoring and evaluating the implementation of a screening programme, and setting up smoking cessation groups
• Developing quality and risk management within an evaluative culture, for example using research evidence to inform decision making about interventions
• Collaborative working for health and well-being, for example developing local partnerships to tackle health issues
• Development of policies, strategies and service, for example analyse local data on access to and uptake of primary care services
• Developing and implementing policy and strategy, for example carrying out a Health Impact Assessment on a proposed planning decision
• Working with and for communities, for example mapping local organizations and holding a community planning event
The Public Health Skills and Career Framework (www.skillsforhealth.org.uk/page/career-frameworks/public-health-skills-and-career-framework) is a tool for describing the skills and knowledge needed across nine levels of the public health workforce whoever the employer and whatever the nature of the work. It provides an overview of the competences and knowledge needed in each area and at each level and links to:
• National Occupational Standards (NOS) – those for public health practice developed by Skills for Health and other sector skills councils, for example community development, health trainers.
• The NHS Knowledge and Skills Framework (NHS KSF) which specifies core competences that are linked to pay and progression.
The concept of competence has aroused much controversy. It can be seen as narrow and mechanistic, focusing on task and not enabling practitioners to acquire the value base essential for critical practice. All practitioners need to be not just technicians but reflective practitioners with a professional literacy. Competences cannot cover all types of activities nor the personal processes entailed in health improvement. In specifying a range of activities in which the practitioner must perform, the role of theory and understanding is diminished. ‘Knowing’ becomes merely preparation for ‘doing’ with no requirement to reflect on theoretical bases or make sense of working practice.
The professional education of many practitioners, particularly in health and education, has been illuminated in recent years by the work of Schon and the concept of the ‘reflective practitioner’. Schon (1983) characterizes professional practice as the high ground of research and theory as swampy lowland that consists of the messy, confusing problems of everyday practice. Schon likens many practitioners to the jazz musician or cook who is highly skilled at what he or she does and because of his or her experience is able to improvise, but who may not know or understand the theoretical basis of musical syncopation or the emulsification of fats. Schon argues that through reflection-in-action a practitioner learns the tricks of the trade and what works in practice. This personal or experiential knowing is an essential part of a practitioner’s understanding. Schon also says, however, that practitioners need to be able to reflect on action and to remove themselves from the swamp of practice and take a broad view. The reflective practitioner is able to integrate these two aspects.
Through this process, links are made between experience, theory and practice. Kolb (1984) argued that if we are to learn effectively, experience needs to be carefully and systematically reflected upon. Practitioners and students in classroom situations who focus on an ‘experience’ or a situation about which they felt uncomfortable may begin to understand the ways in which their knowledge was inadequate for the situation. Through sharing that information they can discover how others experience in a different way something they may have taken for granted. Through analysing or interpreting the issue or situation they can abstract general principles from it. By drawing on theoretical frameworks they can see what further knowledge may be required, and then apply this back to their practice, perhaps trying out new ideas or doing things in a different way. The whole process is a cycle of practice-theory-practice or PRAXIS.
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