Health promotion in the market place: constraints and opportunities

An emerging trend internationally is for health promo tion servicesto be privatised and organised through a division of ‘purchaser’and ‘provider’ functions. This paper examines theconstraints and opportunities for health promotion in the marketplace through a discus sion often ‘vital signs’drawing on British experience where appropriate. If the marketis not closely managed there are considerable concerns thathealth inequalities could increase, that ethical issues couldbe ignored, and that health promotion practice could be seriouslycom promised. Nevertheless, there are also potential benefitsfrom a market economy, but these will only be realised if thereis a shared understanding of the purchaser/provider roles, adequateskills and resources for the purchaser function, earmarked fundingfor health promotion investment, effective monitoring and refereeingby government as ‘regulator’, and training for thenew tasks and responsibilities. To improve pe, formance a distinctionshould be made between health promotion Design, Development,and Delivery-the three ‘Ds’ of health promotionpractice. Tasks for the three stages are described, togetherwith the potential roles of govern ment, public sector agencies,professional bodies, voluntary organisations and private sectorcompanies. Long-and medium-term time scales are essential foreffective implementation.     

Helping people change--an ethical approach?

This paper is a normative analysis of an empowerment approachin health promotion. In particular it utilizes two increasinglyinfluential idioms of normative analysis (analytic health careethics and Foucauldian analysis) to evaluate the ethics of ‘helpingpeople change’. The HEA pack entitled ‘Helping PeopleChange’ (HPC) is used as an exemplary case study and asa starting point for analysis; but the implications are intendedto be more wide ranging and the purpose of the analysis is two-fold.First, ethical discussion is presented as an important dimensionof the substantive evaluation of HPC-type interventions (i.e.interventions which emphasize support for voluntary change).Second, it is presented as a means of comparing and contrastingthe role of the two normative idioms in such ethical evaluation.The aims and the underlying rationale of the HPC pack are setout. Analytic health care ethics is represented by the well-known‘four principles’ approach and the longest sectionof the paper applies each of these principles in turn (beneficence,non-maleficence, autonomy and justice) to the HPC pack. It isargued that for each principle there are ethical difficultiesattaching to HPC-type interventions. This is (albeit superficially)paradoxical given that such interventions are arguably exemplaryand are self-consciously ‘ethical’. It is here thata Foucauldian perspective presents a sharp contrast. Accordingto such a perspective, it is argued, the idea of helping peoplechange is ‘obviously’ questionable. This is becauseFoucauldian analysis centres around the intimate links betweenempowerment, control and ‘the creation of subjects’.Finally, some of the other contrasts between, and the potentialcomplementarity of, the two normative perspectives are brieflyreviewed.     

'Well-being': health promotion's red herring

‘Well-being’ is frequently said to be the ultimategoal of health promotion. However, health promotion author itiesdo no: offer a clear definition of ‘well-being’.Instead health promoters either assume a causal relationshipbetween their activities and the increase of ‘well-being’or claim privileged knowledge of ‘well-being’ andits means of production, or both. These health promotion strategiesare questioned, and it is suggested that the use of ‘well-being’in health promotion acts to obscure the analysis of health promotionphilosophy and practice. It is concluded that either the term‘well-being’ should be given clear and substantialcontent, or it should be discarded by health promoters. Thelatter option is favoured.     

Strategies, guidelines, policies and standards: the search for direction in community health promotion

In this paper, the authors respond on behalf ofa panel representingthe American Public Health Association in the USA to criticismsfrom Canada (by Higgins and Green, two health education researchersfrom British Columbia) regarding the relevance and adequacyof a set of criteria developed in the USA for guiding the developmentof health promotion programs in other developed countries, suchas Canada. The US criteria included a specific focus on riskfactors of disease or untoword health conditions, the characteristicsof an intervention's target group(s), the appropriateness ofan interivention for a given target group or socio-culturalsituation, the optimum use of available resources, and the abilityto evaluate intervention effects. The Canadian criticisms were that these criteria do not allowforor give proper appreciation to the process through which communitiescoalesce around specific problems or issues of importance to‘health’, and there is strong exception taken tothe focus by US groups on ‘risk factor reduction’.There is a preference among Canadians for the tenn ‘riskcondition’, which is defined as ‘local conditionshaving an impact on the health of neighborhoods’. Through a series of case illustrations, the Canadian authorsattempt to show the narrowness of the US criteria, thereforearguing for a broader set of criteria which would allow fora programatic focus on community-based health problems whichare not ‘"carefully deflned measureable, modifiable" riskfac tors’. In response, the authors of this paper argue that their Canadiancritics have misinterpreted the purpose and utility of the APHAguidelines, therefore over-interpreting the implications ofthese criteria for the specific Canadian community health promotioninitiatives they hoped to evaluate. The conclusion reached isthat the APHA criteria continue to represent a useful approachto guiding the consideration of pos sible health promotion investmentson the part of communities or organizations.     

Empowerment: the holy grail of health promotion?

Potentially, empowerment has much to offer health promotion.However, some caution needs to be exercised before the notionis wholeheartedly embraced as the major goal of health promotion.The lack of a clear theoretical underpinning, distortion ofthe concept by different users, measurement ambiguities, andstructural barriers make ‘empowerment’ difficultto attain. To further discussion, this paper proposes severalassertions about the definition, components, process and outcomeof ‘empowerment’, including the need for a distinctionbetween psychological and community empowerment. These assertionsand a model of community empowerment are offered in an attemptto clarify an important issue for health promotion.     

Health education and the ideology of health promotion: a review of alternative approaches

This paper discusses various approaches to the definition of‘health promotion’ and examines the role of theWorld Health Organization in its popularization. Health promotionis conceptualized as any deliberate intervention which seeksto promote health and prevent disease and disability. It incorporates‘health education’ and gives prominence to the influenceof legal, fiscal, economic and environmental measures on communityhealth. Various ‘models’ of health education areexplored and their contribution to health promotion is discussed.It is argued that ‘selfempowerment’ should be themain focus for health education programmes.     

Continuous quality improvement and health promotion: can CQI lead to better outcomes?

Canadian health promotion organizations currently face two pressures.First, is the desire of health promotion organizations to seekmethods which will help achieve health promotion goals. Second,external funders are increasingly likely to require that healthpromotion organizations adopt ‘quality’ procedures,such as Continuous Quality Improvement (CQI). This paper exploresa set of questions that assess the potential benefits of CQIwith respect to health promotion organizations. These questionsinclude: Is the philosophy of CQI compatible with health promotionprinciples, values and beliefs? Is CQI methodology and approachapplicable to health promotion? If there are no irresolvableconflicts between CQI and health promotion, will implementingCQI processes improve health promotion practice? In addition,the paper highlights several issues that health promotion needsto address before adopting CQI, including: the meaning and relevanceof concepts such as ‘customer’ and ‘customersatisfaction’, within the context of health promotion;and the heavy emphasis that CQI places on data that are measurableand quantifiable. While further exploration and documentationare required before definitive resolution of these issues, apreliminary overview indicates that CQI, with some modifications,is compatible with health promotion in at least some circumstancesand that, if these modifications are implemented, CQI couldhelp health promotion achieve its goals.     

Some problems in health promotion research

It is argued that health promotion research faces three criticalproblems: defining adequate research questions; identifyingappropriate areas for research and developing a theoreticalbasis for problem formulation. it is suggested that if healthpromotion research is to be a vigorous part of the emergingdiscipline of health promotion, rather than simply an evaluativetool, and if health promotion research is to be distinguishedfrom epidemiology, sociology, psychology, politics or economicswith a health promotion angle, then these three problems mustbe resolved The origins of the difficulties associated withproblem definition, priority areas for research and adequatetheoretical tools are traced in the first instance to the idealisticand programmatic nature of health promotion and the conflationof ‘is’ and ‘ought to be’ questionsin the idealism. The ‘ought to be’ nature of healthpromotion carries important implications for behavioural andsocial change. It is argued that for the most part the normativeand scientific issues surrounding change have not been disentangledand that neither have the contributions of the disciplines whichhave studied social and behavioural change had much impact onhealth promotion. These problems manifest themselves in studiesand practice involving empowerment, enablement and healthy publicpolicy. it is concluded that the role of research in healthpromotion must be clarified and a shift away from the pathogenicparadigm encouraged.     

Towards a critical social science perspective on health promotion research

As part of our on-going efforts to formulate an alternativeparadigm for health promotion research, we discuss an approachthat we have called a ‘critical social science perspective’(CSSP). This perspective consists of a set of ‘reflexive’questions concerning the implicit assumptions and ideology underlyingthe research process, and the role of power, contradiction anddialectical relationships in theory and research practice. Thepaper briefly outlines key features of a CSSP and models itsapplication to health promotion research by examining why andhow smoking among young girls has emerged as a research issue.We illustrate how the ‘problem’ of young girls smokinghas been construed in terms of epidemiological evidence, scientificimperative, flawed strategy, feasibility, symbolic appeal, vestedinterests and resistance. A CSSP reveals the socio-politicalconstruction of research problems. The paper reflects on theimplications of adopting such a stance to research.     

Thoughts on the ideological origins of health promotion

Health promotion it a relatively new concept and has many implicationsfor both public health and medical sociology. Nonetheless, newideas do not occur in a vacuum, but are part of a context whichit sometimes decipherable and often inscrutable. The followingessay or ‘debate piece’, consists of some ruminationsabout the nature of health promotion, medical sociology andthe ‘new’ public health. It is not intended to provideanswers, but to generate discussion.     

A critical analysis of different leadership approaches to community health work in Kirseberg, Sweden

This paper examines some dilemmas of both professional and communityled approaches in health promotion with reference to an alcoholreduction programme implemented in Kirseberg, Sweden. A ‘traditional’health education programmed designed at changing life-stylehabits was combined with a community action design. The processby which the public health messages were sent to and receivedby the residents was explored in a qualitative study. The study focused on the possibly contradictory relationshipbetween the ‘professional’ concept of public healthand individuals' personal concepts of health. it is argued thatif the ‘top down’ and ‘bottom up’ approachesare combined without detailed consideration being given to thepossible connecting links the risk is that the result will bethe operation of two parallel strategies which do not interact. The process of making health a collective issue within a communityaction programme is illustrated with examples from the Kirsebergproject and discussed with reference to the chief aim of achievingequity in health provision.     

Capturing the meaning of 'community' in community intervention evaluation: some contributions from community psychology

Evaluations of community health promotion can underestimatethe gains that an intervention might make in a community ifthe outcomes reported are limited to aggregates of changes inhealth behaviour or attitude made at an individual level Thenotion of ‘community’ revealed by this type of evaluationis relatively unsophisticated compared to the ‘community’rhetoric which often accompanies program definition. Even thoseevaluations which report policy changes or evaluations of howcommunities became involved, often fail to capture the improvementsa community intervention can make on the problem-solving capacitiesof a community and its competence in tackling the issues whichface it. The essence of what some interventions (intentionallyor unintentionally) achieve is, therefore, missed. Empowerment is usually described as a process. But it can beconsidered as an outcome variable in community interventionsif capacity-building is a major activity of an intervention.To capture this in the evaluation design, evaluators shouldbe using active strategies to (i) articulate what empowermentactually means and (ii) challenge what intervention successreally means in interactive dialogues with program workers andthe community. Active and interactive strategies must be usedto clarify program values and intentions because evaluatorswill be misled or confused by words like ‘community involvement’,‘community development’ or ‘community participation’in program documents. These words mean different things to differentgroups. Similarly, ‘empowerment’ must be translatedinto aspects which are recognisable within the life of the programor period of interest. Community psychology is introduced in this paper as a fieldwhich may have much to offer in this analysis. Community psychologyis a field within psychology which should be distinguished fromthe more traditional approaches in community-based health promotionwhich are the legacy of behavioural health psychology.     

The efficacy of health promotion, health economics and late modernism

This paper argues that the application of health economics tothe evaluation of health promotion strategies provides an exampleof the application of a modernist framework to an inherentlylate modern practice. The hegemony of health economics is explainedin terms of the organizational need for ‘ontological security’that the rhetoric of rationality provides in an era of inherentchange and disorder. In the light of this argument the paperexamines the most developed framework for evaluating the cost-effectivenessof health promotion.     

'If I let a goal in, I'll get beat up': contradictions in masculinity, sport and health

This paper presents a critical exploration of the relationshipbetween masculinity, sport and health by reporting findingsfrom a wider qualitative study on lay men’s and healthprofessionals’ beliefs about masculinity and preventativehealth care. Recent years have seen a surge of interest in relationto ‘men’s health’. In particular, the Departmentof Health has highlighted how men’s connection to sport,fitness and competitiveness can be used in health promotioninitiatives to introduce facets of health. In contrast, workin the sociological and feminist literature has raised issuesof concern about the relationship between men, masculinity andsport, particularly the links to aggression, misogyny and homophobia.It would appear then that a straightforward ‘men + sport= health’ relationship cannot be assumed. Focus groupsand interviews with health professionals and men, includinggay and disabled men, were undertaken to facilitate examinationof the socially integrative meanings of sport and masculinity,and their relationship to health. Socializing, ‘macho’culture and the body emerged as three main themes, and the implicationsof these empirical findings for health promotion are discussed.     

Muddling through the middle ground: theoretical concerns in intersectoral collaboration and health promotion

This paper considers the conceptual basis of intersectoral collaboration(ISC) in health promotion. It summarises concepts and perspectiveswithin literature loosely labelled as ‘interorganisationalrelations’. These are applied to health promotion, specificallythe development of healthy public policy at local level. Whilethe importance of collaboration and working together at practitionerlevel is acknowledged, the main emphasis is on strategic levelcollaboration and policy coordination. The aim is to consolidateunderstanding of the concept, its features and its ‘determinants’.Ways in which collaboration might be fostered are considered.     

Using sponsorship to create healthy environments for sport, racing and arts venues in Western Australia

The development of healthy public policy and the creation ofenvironments that support health are two of the Ottawa Charter'sgoals for health promotion action. The Western Australian HealthPromotion Foundation (referred to as ‘Healthway’)is an independent statutory body funded by a levy raised onthe wholesale sales of tobacco products. Healthway's legislativecharter defines a number of objectives for the Foundation. Theseinclude: funding activities related to the promotion of goodhealth; offering an alternative source of funds for sport, racingand arts activities previously supported by tobacco sponsorship;and supporting sport, racing and arts activities that encouragehealthy lifestyles and advance health promotion programs. Healthwayhas interpreted this charter from a health promotion perspectiveand ties the offer of sponsorship to sport, racing and artsorganisations with policies that create healthy environments.While the major focus of Healthway's healthy public policy interventionshas been the creation of smoke-free environments, importantgains have also been made in the provision of healthy food choices,safe alcohol practices, sun protection policies and access fordisadvantaged groups. This paper describes the results of asurvey of organisations funded by Healthway and explores theprevalence and reach of structural reforms in sport and culturalsettings. The development of structural reform policies amongdifferent types of organisations receiving different levelsof sponsorship is described. While not all of the structuralreforms observed in this survey can be attributed to Healthway,it is clear from the research that Healthway has contributedto the rate of policy development amongst ‘structuralreform laggards’. The implications for ‘active encouragement’of intersectoral co-operation through government sponsored grantsis discussed.     

Applying logics of change to the evaluation of community development in health promotion

Evaluation of community-oriented health promotion programs requirethat professional evaluators clearly distinguish between exogenouslyand endogenously defined goals and definitions of ‘success’.Acknowledging the different dynamics which underpin community-ledchange and externally initiated health programs and interventionsis essential to this task. It will be argued that the intersectionof, and boundaries around, exogenous and endogenous change canbest be understood and clarified through the application of‘logics of rationality’, adapted from social theory.Community activity is characterised by what we have called ‘lifeworldrationality’ community-based health promotion interventionsare characterised by ‘formal ratonality’. In addition,we suggest that the value dimensions (‘substantive rationality’)underpinning programs and interventions may be overlooked bypolicy makers, program planners and professional evaluatorsunder pressure to demonstrate cost-effectiveness and efficiency.Key requirements for successful and appropriate evaluation ofcommunity-based programs which are sensitive to the needs andsuccess criteria of communities include a shared understandingby the researchers, program sponsors and community actors ofthe nature of the changes sought. The co-production of healthpromotion standards and of indicators to judge the performanceof the program or intervention by all stakeholders should bepreferred over the trend for establishing community-controlledprocess evaluations to coexist alongside expert-controlled impactevaluations. It is argued that current approaches to standardsetting and indicator development to judge the processes andimpacts of interventions are inadequate and several principlesfor improving their content are given. A locally controlledethnographic approach to evaluate endogenous community-led changeis described in the hope that program planners and evaluatorsmay become more sensitive and receptive to local knowledge.We suggest that engagement with what we have termed the ‘communitystory’ should be a fundamental requirement for the planningand evaluation of community health programs.     

Health promotion policies in Singapore: meeting the challenges of the 1990s

Health promotion has been proposed as one of the major elementsin national health policies in Singapore by the Review Committeeappointed by the Minister for Health in April 1991. This articlelooks at health promotion policies in Singapore, including theconcept, approach, targets, outreach programmes, and frame-workfor actions, with particular reference to the Ottawa Charterfor Health Promotion and Adelaide Recommendations. The Singaporestrategies focus mainly on healthy lifestyle promotion, whichhas taken the form of a nationwide campaign, in the hope to‘add years to life’ as well as ‘life to years’among Singaporeans.     

Health promotion, advocacy and health inequalities: a conceptual framework

Advocacy has often been described as a key strategy for theachievement of health promotion aims, but multiple and conflictingdefinitions and usages exist. The concept itself may be unnecessarilyintimidating. Advocacy work can take place at the level of both‘cases’ and ‘causes’. Two main goalsunderpin health advocacy—protection of the vulnerable(representational advocacy) and empowerment of the disadvantaged(facilitational advocacy). This paper attempts to integrateexisting models and definitions into a conceptual frameworkfor considering the role of advocacy in addressing health inequalities.It argues that we need to pay some attention to the diversityof values and goals of health promotion if we are to understandwhich models and approaches to health advocacy apply and inwhat context. This paper concludes that advocacy for healthfulfils two functions: as a form of practice and as a usefulstrategy for a discipline which has to be self-promoting aswell as health-promoting in order to survive in the competitivepolitical environment of contemporary health work.     

A methodology for estimating the costs and benefits of health promotion

The publication of ‘The Health of the Nation’ [Departmentof Health (1992) The Health of the Nation. A Strategy for theHealth of England. CM 1986, HMSO.] has added increased emphasisto the long standing debate concerning the relative cost-effectivenessof health prevention versus health cure. The benefits arisingfrom curative interventions are highly visible, occur in identifiableindividuals and can be quantified using an increasing stockof clinical and quality of life measures. Unfortunately thebenefits of health promotion activities are much more difficultto quantify and measure given that their success depends uponill health not occurring. In order for health promotion to effectively compete for limitedhealth care resources it must ensure that the benefits of itswork are apparent to policy makers. This paper describes a methodologyby which such benefits can be quantified in readily measurableterms. This enables health promotion to make an effective casefor additional resources using ‘hard’ quantifieddata that emphasizes the value for money and health gain (orrather the prevention of health loss) that can be derived frominterventions of this nature. The methodology is based on readilyavailable data relating to the levels of morbidity and mortalityexperienced by any given population. Epidemiological data isthen utilized to quantify the link between ill health and theproblem being addressed by the health promotion activity. Themodel described in this paper was tested in relation to theanticipated impact of an anti-smoking programme upon the healthexperience of the population within the North West of England.