'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.     

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.     

Health, human development and the community ecosystem: three ecological models

Health, as both an expres and a component of human development,has to be seen in an ecological way as ‘the pattern thatconnects’ and the radical and subversive nature of anecological approach needs to be recognized. Three ecologicalmodels are presented, that of health, the links between health,environment and economy (or between ‘health for all’and sustainable development); and the social, environmentaland eco nomic dimensions of a healthy and sustainable com munity. The ‘Mandala of Health’, as a model of the humanecosystem, presents the determinants of health as a set of nestedinfluences, ranging from the biological and personal to theecological and planetary, including the social and political The health-environment-economy model shows the crucial linksbetween health (or social wellbeing) and environmental and economicwellbeing with a particular focus on two key public health principles—equityand sustainabilizy. The final model applies these concepts atthe community level, introducing such issues viability, convivialityand liveabilily. These models could be used to better understand health, to definekey criteria for hea Ithier public policies and to define somekey action areas for healthy city projects. It is in their applicationthat their value—and their ‘subversiveness’—willbe tested.     

Evaluation in Health Promotion: Principles and Perspectives: Irving Rootman, Michael Goodstadt, Brian Hyndman, David V. McQueen, Louise Potvin, Jane Springett and Erio Ziglio (eds) WHO Regional Office for Europe, Copenhagen (2001) 533 pp. ISBN 92-890-1359-1

This compendious work on evaluation consists of 23 chaptersincorporating contributions from 52 internationally recognizedauthors in the field of evaluation and health promotion. Readingit is a not insubstantial task—but certainly worth theeffort. The book, like Gaul, is divided into three main parts. One ofthese, labelled ‘Perspectives’, consists of eightchapters that offer a variety of valuable insights into keyissues that are at the heart of contemporary debate about evaluatinghealth promotion initiatives. The authors clearly demonstrateone of the main reasons why the ‘gold standard’,randomized controlled trial is entirely inappropriate to     

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 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.     

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.     

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.     

Toward an ethic of empowerment for health promotion

This paper lays out a conceptual framework for articulatingsome main ethical issues raised by health promotion and illnessprevention. Building from the concept of ‘enabling’in the Ottawa Charter, the paper articulates and advocates an‘ethic of empowerment’ for health promotion. If health promotion is understood in terms of enabling, thetired ethical debates between freedom and responsibility, orindividual and community, are recast in a new and more productivelight. Health promotion should resist the temptations of eithera coercive, paternalistic ethic or an individualistic, laissez-faireethic in favour of an ethic of enabling or empowerment.     

'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.     

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.     

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.     

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.     

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.     

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.     

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.     

Lessons from community participation in health programmes

Although primary health care emphasizes community participationand many health care programmes attempt to develop participation,good analysis of these developments is still rare. This paper,based on a review of about 200 case studies, examines some ofthe lessons for planners which are emerging from experiencesof the last decade. These lessons focus on the problems of definingthe term ‘community participation’, of gaining andsustaining broad-based community participation, of failing torecognize the political implications of the concept and of attemptingto develop a management model of community participation forhealth. Based on these lessons, a planning framework is suggestedthat seeks individual programme answers to three questions:‘Why participation?’, ‘Who participates?’,‘How do they participate?’. The answers to thesequestions will help to define a programme's objectives and tomonitor and evaluate its development.     

Twenty years since Ottawa and Epp: researchers' reflections on challenges, gains and future prospects for reducing health inequities in Canada

November 2006 marked the 20-year anniversary of the Ottawa Charterfor Health Promotion and Canada's Epp Report. Encapsulatingthe tenets of health promotion (HP), these publications articulateda vision for reducing health inequities, and described a policyframework for achieving this vision, respectively. These documentsalso triggered the launch of the population health (PH) field,focused on elucidating the empirical relationships between socioeconomicgradients and population health inequities. Over two decades,a rich HP/PH theoretical and evidentiary base on socioeconomicgradients in health has established. Yet, despite valuable contributionsfrom Canadian researchers, insufficient headway has been madein this country to achieve the Charter's vision. There are numerous challenges to reducing population healthinequities in Canada. Informational challenges include complexityof HP/PH evidence, and inadequate knowledge translation beyondtraditional targets. Institutional challenges include the relativeimmunity of the healthcare sector to funding reductions, andthe organization of policy responsibilities into silos. Concernsfrom non-healthcare sectors of ‘health imperialism’,and inter-governmental tensions are interest-related challenges,while ideological challenges include lack of media discourseon health inequities and a strong neo-liberal political climate. Gains have been made in Canada towards reducing health inequities.The HP/PH discourses are firmly entrenched in academic and policyspheres across the country, while several inter-sectoral policyinitiatives are currently underway. HP/PH researchers couldbe more proactive in the knowledge-translation sphere by engagingother researchers outside of medicine and health, non-healthcarepolicy-makers, and the general public, vis-à-vis themedia, on the health inequities knowledge base. Ultimately,significant and sustained progress will only be made if researchersand other champions recognize the inherently political aspectof their work and understand how to overcome ideologically drivenresistance.