Political ecology, ecological economics, and public health: interfaces for the sustainability of development and health promotion

This article proposes to focus contributions from political ecology and ecological economics to the field of collective health with a view towards integrating the discussions around health promotion, socio-environmental sustainability, and development. Ecological economics is a recent interdisciplinary field that combines economists and other professionals from the social, human, and life sciences. The field has developed new concepts and methodologies that seek to grasp the relationship between the economy and ecological and social processes such as social metabolism and metabolic profile, thereby interrelating economic, material, and energy flows and producing indicators and indexes for (un)sustainability. Meanwhile, political ecology approaches ecological issues and socio-environmental conflicts based on the economic and power dynamics characterizing modern societies. Collective health and the discussions on health promotion can expand our understanding of territory, communities, and the role of science and institutions based on the contributions of political ecology and ecological economics in analyzing development models and the distributive and socio-environmental conflicts generated by them.     

Education for health professionals in the emerging market economies: a literature review

Medical Education 2010: 44 : 856–863 Context Along with economic growth and social reforms, the emerging market economies (EMEs) are undergoing restructuring of their health care systems. There is now an increased focus on disease prevention and primary care, along with a patient‐centred approach to health care delivery. However, these changes need to be complemented by alterations in the health care education system. Methods A review of the published literature, limited to the last 10 years, was conducted to include recent updates on medical and nursing education. This was done by systematically searching appropriate databases using keywords. This review covers only the common issues related to education and training in EMEs. Results Issues identified included: the mismatch between the health needs of the population and education curricula; outdated curricula and teaching methods; growing numbers of medical schools; the quality of education, and inadequate career guidance for students to help them make decisions about choosing a health profession as a career and, later, about choosing a field of specialisation. Conclusions The literature provides evidence of innovative approaches adopted in several EMEs, which include: outcome‐based education; community‐oriented medical education; problem‐based learning; initiatives to improve quality, and initiatives to resolve the shortage of skilled educators for medical and nursing schools. The health care systems in EMEs are undergoing changes imposed by economic, political and social transition. Reforms in health systems will need to be complemented by educational reforms. Education systems require to be updated through needs‐based comprehensive curriculum design and innovative teaching methods. The challenges imposed by the growth in the number of public and private institutions and the need for a standardised accreditation system for quality assurance demand attention. The profiles of both family medicine and community health care will need to be raised and their status enhanced to attract high‐calibre students to these specialties.     

Work and Inter-subjectivity: a theoretical reflection on its dialectics in the field of health and nursing

This theoretical reflection intends to show the inter-subjective relationship that takes place in health and nursing practices under the following theoretical perspectives: Institutional Analysis, Psychodynamics of Labor and the Theory of Communicative Action, with an emphasis on the latter. Linking these concepts to the Marxist approach to work in the field of health emerges from recognizing the need for its continuous reconstruction-in this case, with a view to understand the interaction and communication intrinsic to work in action. The theory of Communicative Action seeks to consider these two inextricable dimensions: work as productive action and as interaction. The first corresponds to instrumental action based on technical rules with a production-guided rationale. The second refers to the interaction that takes place as communicative action and seeks understanding among subjects. We assume that adopting this theoretical perspective in the analysis of health and nursing practices opens new possibilities for clarifying its social and historical process and inter-subjective connections.     

Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice

There is increasing recognition in the health promotion and population health fields that the primary determinants of health lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many nations--and this is especially the case in North America--recent policy decisions are undermining these social determinants of health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of social democracies--the political systems that seem most amenable to securing the social determinants of health--are identified as key to promoting health. Health promoters and population health researchers need to "get political" and recognize the importance of political and social action in support of health.     

Polychlorinated biphenyls in the electrical machinery industry: an ethnological study of community action and corporate responsibility

Environmental and occupational health problems cannot be understood through purely medical and epidemiological analyses, the social forces affecting biologically adaptive behavior must also be analyzed. Research on the political economy of health needs to generate an ethnology of community action relevant to the analyses of corporate structures for which it is best known. In studying the community of Pittsfield, Mass., where a General Electric plant is located, we encountered environmental and occupational health problems in just this context. This essay is, therefore, an effort to extend the political economy of health into the ethnological domain of community research.     

Obesity and climate change mitigation in Australia: overview and analysis of policies with co‐benefits

Objective: To provide an overview of the shared structural causes of obesity and climate change, and analyse policies that could be implemented in Australia to both equitably reduce obesity rates and contribute to mitigating climate change. Methods: Informed by the political economy of health theoretical framework, a review was conducted of the literature on the shared causes of, and solutions to, obesity and climate change. Policies with potential co‐benefits for climate change and obesity were then analysed based upon their feasibility and capacity to reduce greenhouse gas emissions and equitably reduce obesity rates in Australia. Results: Policies with potential co‐benefits fit within three broad categories: those to replace car use with low‐emissions, active modes of transport; those to improve diets and reduce emissions from the food system; and macro‐level economic policies to reduce the over‐consumption of food and fossil fuel energy. Conclusion: Given the complex causes of both problems, it is argued that a full spectrum of complementary strategies across different sectors should be utilised. Implications: Such an approach would have significant public health, social and environmental benefits.     

The debate on climate change and health in the context of ecological public health: a necessary corrective to Costello et al.'s ‘biggest global health threat’, or co-opted apologists for the neoliberal hegemony?

The threat posed to global health by climate change has been widely discussed internationally. The United Kingdom public health community seem to have accepted this as fact and have called for urgent action on climate change, often through state interventionist mitigation strategies and the adoption of a risk discourse. Putting aside the climate change deniers' arguments, there are critics of this position who seem to accept climate change as a fact but argue that the market and/or economic development should address the issue. Their view is that carbon reduction (mitigation) is a distraction, may be costly and is ineffective. They argue that what is required is more economic development and progress even if that means a warmer world. Both positions however accept the fact of growth based capitalism and thus fail to critique neoliberal market driven capitalism or posit an alternative political economy that eschews growth. Ecological public health, however, appears to be a way forward in addressing not only social determinants of health but also the political and ecological determinants. This might allow us to consider not just public health but also planetary health and health threats that arise from growth based capitalism.     

Social determinants of health: present status, unanswered questions, and future directions.

This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and evidence on the impact of various social determinants of health. The contributions of different disciplines--epidemiology, sociology, political economy, and the human rights perspective--to the field are acknowledged, but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The author identifies the areas of inquiry needed to help translate knowledge into action.     

Re-orienting public health: rhetoric,challenges and possibilities for sustainability

We make a case in this article for re-orienting public health, based on evidence that societies across the globe are now facing inevitable change for which public health remains insufficiently prepared. We focus on the relationship between different sustainability ideals, displayed through rhetoric and discourse and the reality of a number of challenges in the ‘modern’ world. We briefly describe discernible elements of public and policy rhetoric around sustainability, as an important background for public health efforts, and present two significant public health discourses. We then outline some of the challenges to sustainability; some relate to the powerful social systems and cultural values associated with modernity, while others refer to broader environmental issues. These are not unconnected. We conclude by outlining the possibilities for sustainability, which include a transition to a more sustainable form of society that could lessen global inequalities, combat emerging problems, such as obesity, depression and addictive behaviours, and improve individual and social levels of well-being. We believe that this may well require a change of consciousness for a change of age, so the scope and scale of the required response should not be underestimated.     

Strengthening community mental health competence—A realist informed case study from Dehradun,North India

Few accounts exist of programmes in low‐ and middle‐income countries seeking to strengthen community knowledge and skills in mental health. This case study uses a realist lens to explore how a mental health project in a context with few mental health services, strengthened community mental health competence by increasing community knowledge, creating safer social spaces and engaging partnerships for action. We used predominantly qualitative methods to explore relationships between context, interventions, mechanisms and outcomes in the “natural setting” of a community‐based mental health project in Dehradun district, Uttarakhand, North India. Qualitative data came from focus group discussions, participant observation and document reviews of community teams' monthly reports on changes in behaviour, attitudes and relationships among stakeholder groups. Data analysis initially involved thematic analysis of three domains: knowledge, safe social spaces and partnerships for action. By exploring patterns within the identified themes for each domain, we were able to infer the mechanisms and contextual elements contributing to observed outcomes. Community knowledge was effectively increased by allowing communities to absorb new understanding into pre‐existing social and cultural constructs. Non‐hierarchical informal community conversations allowed “organic” integration of unfamiliar biomedical knowledge into local explanatory frameworks. People with psycho‐social disability and caregivers found increased social support and inclusion by participating in groups. Building skills in respectful communication through role plays and reflexive discussion increased the receptivity of social environments to people with psycho‐social disabilities participation, thereby creating safe social spaces. Facilitating social networks through groups increases women's capacity for collective action to promote mental health. In summary, locally appropriate methods contribute most to learning, stigma reduction and help‐seeking. The complex social change progress was patchy and often slow. This study demonstrates a participatory, iterative, reflexive project design which is generating evidence indicating substantial improvements in community mental health competence.     

Politics, welfare regimes, and population health: controversies and evidence

In recent years, a research area has emerged within social determinants of health that examines the role of politics, expressed as political traditions/parties and welfare state characteristics, on population health. To better understand and synthesise this growing body of evidence, the present literature review, informed by a political economy of health and welfare regimes framework, located 73 empirical and comparative studies on politics and health, meeting our inclusion criteria in three databases: PubMed (1948-), Sociological Abstracts (1953-), and ISI Web of Science (1900-). We identified two major research programmes, welfare regimes and democracy, and two emerging programmes, political tradition and globalisation. Primary findings include: (1) left and egalitarian political traditions on population health are the most salutary, consistent, and substantial; (2) the health impacts of advanced and liberal democracies are also positive and large; (3) welfare regime studies, primarily conducted among wealthy countries, find that social democratic regimes tend to fare best with absolute health outcomes yet consistently in terms of relative health inequalities; and (4) globalisation defined as dependency indicators such as trade, foreign investment, and national debt is negatively associated with population health. We end by discussing epistemological, theoretical, and methodological issues for consideration for future research.     

Educating for collaborative practice: an interpretation of current achievements and thoughts for future directions

Context

The Edinburgh Declaration, developed in 1998 as a pledge to alter the character of medical education to more effectively meet the needs of society, included a recommendation to increase the opportunity for joint learning between health and health‐related professions, as part of the training for teamwork. This article acknowledges achievements since the Declaration in relation to this recommendation, using an umbrella term for the phenomenon, ‘educating for collaborative practice’, and presents a perspective framed as a series of questions to encourage reflection on future directions.

Methods

A literature interpretation, informed by philosophical hermeneutics, was conducted using text sets comprising reports and reviews from a section of the international literature since 1988. The interpretation involved: engaging with meanings as presented in the chosen texts; making iterative returns to the texts to explore emerging understanding; and ensuring parts of our understanding from particular texts were fused with complete understanding of the texts as a whole. A lens of appreciative inquiry facilitated acknowledgement of what has been achieved, while being curious about how it could be.

Results

Interpretation of the selected literature revealed notable achievements. Areas for further consideration were identified in relation to three themes: establishing shared understanding AND purpose behind use of terminology; being a conduit AND sharing responsibility for change; exploring ways of doing things AND ensuring ongoing inclusivity.

Conclusions

Interpreting the current literature on ‘educating for collaborative practice’ has generated questions for reflection on how it may be otherwise. Readers are encouraged to embrace the tensions inherent in unanswered questions, providing space for communication, initiative and diversity of thought. An ongoing dialogue with the literature is proposed, asking whether educating students for a collective identity in settings where they are learning for and with patients is likely to advance educating for patient‐centred collaborative practice.     

Editorial – Wicked problems and Health Promotion: reflections on learning

What do complex issues such as inequity, climate disruption, food insecurity and obesity challenge us to learn? These are wicked problems that require action at every scale. With multiple, interacting causes, solutions lie well beyond the traditional domain of any one jurisdiction or organisational entity, and beyond business‐as‐usual. A discourse is emerging in health promotion literature on relevant new perspectives and practitioners now appear to be poised at a significant learning threshold.     

Can nursing epistemology embrace p‐values?

The use of correlational probability values (p‐values) as a means of evaluating evidence in nursing and health care has largely been accepted uncritically. There are reasons to be concerned about an uncritical adherence to the use of significance testing, which has been located in the natural science paradigm. p‐values have served in hypothesis and statistical testing, such as in randomized controlled trials and meta‐analyses to support what has been portrayed as the highest levels of evidence in the framework of evidence‐based practice. Nursing has been minimally involved in the rich debate about the controversies of treating significance testing as evidentiary in the health and social sciences. In this paper, we join the dialogue by examining how and why this statistical mechanism has become entrenched as the gold standard for determining what constitutes legitimate scientific knowledge in the postpositivistic paradigm. We argue that nursing needs to critically reflect on the limitations associated with this tool of the evidence‐based movement, given the complexities and contextual factors that are inherent to nursing epistemology. Such reflection will inform our thinking about what constitutes substantive knowledge for the nursing discipline.     

Social inequities and contemporary struggles for collective health in Latin America

ABSTRACT

As part of a planned series from Global Public Health aimed at exploring both the epistemological and political differences in diverse public health approaches across different geographic and cultural regions, this special issue assembles papers that consider the legacy of the Latin American Social Medicine and Collective Health (LASM-CH) movements, as well as additional examples of contemporary social action for collective health from the region. In this introduction, we review the historical roots of LASM-CH and the movement’s primary contributions to research, activism and policy-making over the latter-half of the twentieth century. We also introduce the special issue’s contents. Spanning 19 papers, the articles in this special issue offer critical insight into efforts to create more equitable, participatory health regimes in the context of significant social and political change that many of the countries in the region have experienced in recent decades. We argue that as global health worldwide has been pushed to adopt increasingly conservative agendas, recognition of and attention to the legacies of Latin America’s epistemological innovations and social movement action in the domain of public health are especially warranted.     

A systems-in-transition paradigm for healthy communities.

WHO is generating a new approach to public health in many nations. In Canada the new public health has stimulated important innovations such as the Health Promotion Framework in Achieving Health For All and the Canadian Healthy Communities Project. There is a need, however, for a political theory of social organization and change to facilitate social and political analysis of communities. This article proposes a paradigm which organizes community using a structural-functional approach linked with process components addressing community change through development, stress and conflict. A new definition of a healthy community is proffered using the language of the model. The emerging political role of community health practitioners in the new public health is described.     

Agenda de género en la formación en ciencias de la salud: experiencias internacionales para reducir tiempos en España

ObjectiveTo analyse experiences and lessons learned in the process of incorporating gender perspective into health sciences degrees in the international arena.MethodNarrative literature review with no date limit. Keywords “curricula”, medical education”, “nursing education”, “health science”, “gender education”, “gender medicine” and “gender health issues”. Other articles were snowballed from those identified in the review.ResultsContent on sex-gender appears in learning outcomes and evaluation. Learning based on discussing innovations and assistive applications on gender issues. Resistance: scepticism as a useful academic exercise; lack of time for teacher training and difficulty in finding concrete solutions, due to the diversity of contents; Curriculum overload; the idea of dealing exclusively with women's issues. Difficulties in implementing change policies in centres arising from the difficulty in identifying and presenting gender biases to academic authorities.ConclusionsThe key to gender mainstreaming in university degrees lies at the level of political, organizational and cultural change, as well as at faculty level. There are facilitating factors and individual and interpersonal barriers; the organizational level is essential with institutional support through norms that enforce the incorporation of this perspective and ensure its sustainability.     

The influence of the Community‐based Health Planning and Services (CHPS) program on community health sustainability in the Upper West Region of Ghana

Ghana introduced Community‐based Health Planning and Services (CHPS) to improve primary health care in rural areas. The extension of health care services to rural areas has the potential to increase sustainability of community health. Drawing on the capitals framework, this study aims to understand the contribution of CHPS to the sustainability of community health in the Upper West Region of Ghana—the poorest region in the country. We conducted in‐depth interviews with community members (n = 25), key informant interviews with health officials (n = 8), and focus group discussions (n = 12: made up of six to eight participants per group) in six communities from two districts. Findings show that through their mandate of primary health care provision, CHPS contributed directly to improvement in community health (eg, access to family planning services) and indirectly through strengthening social, human, and economic capital and thereby improving social cohesion, awareness of health care needs, and willingness to take action at the community level. Despite the current contributions of CHPS in improving the sustainability of community health, there are several challenges, based on which we recommend, that government should increase staffing and infrastructure in order to strengthen and maintain the functionality of CHPS.     

Bureaucratic logic in new social movement clothing: the limits of health promotion research

This paper discusses theoretical, methodological and politicalproblems in the field of health promotion research. It arguesthat these problems result from a partial and contradictoryappropriation of the discourse of new social movements. Politically,the health promotion movement is largely confined within thestate, rather than the expression of a social movement againstthe state. The direction of health promotion research and policyis, therefore, caught in the bureaucratic logic of ‘trappedadministrators’, and results in contradictory emphaseson problems like the development of ‘health promotionindicators’, which show little result in informing a broaderbut coherent conceptualization of health, let alone in effectingchange in health policy and outcomes. Such political problemsreflect parallel confusions about theory and methodology. Theoretically, the field relies heavily on a critique of bio-medicalscience, but fails to move beyond a rhetorical outline of analternative to systematic arguments about what promotes health.In this regard, the literature on health promotion remains unawareof important conceptual developments in the social sciences,relies on imprecise specifications of major constructs likecommunity empowerment, and has no conception of the state. Methodologically,the literature is influenced by contradictory epistemologicaltendencies which reflect a positivist inspiration (as in thesearch for indicators) and an anti-positivist emphasis on agencyand social change through the collective action and the discursivereconstitution of social identity, value and meaning. In regardto these questions, this paper is critical of observers whosuggest that the way ahead is to embrace post-modern researchstrategies. Movement in this direction would tend to diffusean already desultory research practice and depoliticize socialstruggles for meaningful change. The paper ends by suggestingthat the field of health promotion needs a more serious engagementwith critical social theory to construct a rigorous conceptualizationof health and its social correlates and to develop a coherentresearch practice and political project.