The aim of this piece is to cluster a few issues together which I think from my best recollection may be worth examining in order to assess health promotion and public health practice in their broadest forms. This is largely to position Baric’s settings approach alongside other health promotion practice in order to highlight the broader political environment that health promotion practice takes place within. The use of three levels of analysis of health promotion practice is argued to be potentially useful in terms of identifying processes in practice which can inform debate on potential changes likely to take place within the health service at large. These come from the structure used in Wayne Parsons book, Public Policy. First, I would hope to make a point about theorising in health promotion, that it is largely a practice that has been unsuccessful in recent years. Occasionally models of health promotion have been described as ‘iconic’ in the sense they are a representation of practice, a post-hoc reconstruction, rather than being a determinant of practice in the field. In saying that they are used only to describe practice to outsiders to the field rather than being used to direct projects and programs of action. What I propose as an overall theory of health promotion as a mechanism for improving a locality’s health which reflects the politics of the lead organisations as well as the meso-level action which takes place within the settings approach. Macro, meso and micro levels of action of health promotion need to be considered simultaneously in order to ensure that ethics of health promotion practice are considered for all participants. Settings approaches as a meso-level of intervention tend only to be concerned with a particular level of action of health promotion and may as a result whereas the other levels of discourse analysis may indicate that there are more significant levels of action to consider at micro and macro levels of action.
For the purposes of defining roles within health promotion delivery three separate levels of analysis of health improving delivery are defined. The most strategic and highest in terms of the status of the personnel who would normally deliver this would be the macro level of analysis. Overall strategic responsibility for a locality rests with the Director of Public Health whose duties should include examination of qualitative and quantitative data for the locality in order to assess the most suitable types of intervention, combinations of these and means to evaluate against qualitative and quantitative measures. The role of the Director of Public Health is also to assess the nature of the political environment and to have staff in place who can best assist with the development of programs and projects which will ensure health improvement and illness reduction in order to best assist with the goal of dealing with health problems in the defined locality. Health improvement on this level involves assessment of opportunity and threat to project development and assessment of potential gains in health within the strategic context of sometimes thousands of staff. This will involve assessment of potential sites for action on a meso and micro level.
On a meso-level, concerned with organisational change responsibilities linked to dealing with health improvement through organisational change, that is through community, school, workplace or other specific locations for health promotion to be delivered within. Also, adapting existing health service practice through training and arguably organisational development the health promotion team would be seeking to deliver. This tends to work on a model of the Director of Public Health having the lead responsibility for shaping the nature of organisational change within their locality in order to assist with health improvements.
On a micro level, the individual management of health improvement through a one-to-one therapeutic situation could be seen to take place, that is the responsibility of health services staff and professions in related fields who deal with the public in individual interaction or small group interaction.
In some respects the management of population health will be an issue that is a concern for the general practitioner and the individual practice nurse who both may deal with micro level interaction for the majority of their working time. This does not of course preclude them from participating on the level of strategist in terms of their contribution to feedback on strategies and whether or not they are deliverable. Nor would there be a restriction on the general practitioner acting to influence the health and well being of the population for a smaller population size than is managed by a Director of Public Health.
The terminology may be a little cumbersome, the terms macro, meso and micro tend not to be widely used. This could of course reduce any well meaning impact and perhaps strategic, organisational and individual levels of action of public health and health promotion practice could be considered as being a more straightforward and user friendly set of terms.
An initiative like the World Health Organisation’s Healthy City initiative has aims to improve the strategic functions for a city wide area partly through the prestige that can be added through World Health Organisation accreditation for a local government initiative. This would normally involve public sector initiatives that make an impact upon the health and well being of individuals who live and work in the city. Through setting up a partnership body which has a responsibility to coordinate resources in a city more effectively there is potential for influence over the role that a Director of Public Health has although the same function should be served by a number of professionals in this situation in terms of the strategic roles within the health authority.
In terms of how potential advances can be made through examination of practice social theory can be used to highlight some of the processes of social change which are necessary to understand in order for more stakeholders in the change process to influence how resources are distributed in their locality. The research I undertook at M.Sc. level was concerned with the nature of the language that was necessary to use in order to establish an approach to health promotion using discourse analysis as a means to dissect several editorial articles which proposed various approaches to improving health and reducing illness. The articles drew heavily on a number of discourses and each approach to health was supported by drawing upon a number of diverse discourses. Discourses here is intended to convey an institutional dimension of language, in that an established means of dealing with situations or issues in life is dependent upon identifying roles and relationships between participants and language is used to establish the relationship between participants in this context. The notion that acknowledged relationships and how these shape power relations between individuals is what an ‘institution’ is stated to be, that it is a social phenomenon, rather that being an institution in a more Victorian sense where a body or organisation would be established through having a lead individual, premises and a role acknowledged by government. This new institutionalism, very different to the older style of institutionalism, is one area which is a necessary prerequisite for understanding how institutions can be represented in language and sometimes in language alone without material resources to support them. As an example of an institution that has presence in socieity I use psychoanalysis. Although there are recognised bodies still in existence that support psychoanalysis such as psychological associations, in terms of new institutionalism there could be deemed to be a relationship between psychiatrist and patient, the patient being comprised of several psychodynamic phenomena such as an id and an ego, the psychiatrist having the power to define the individual and the nature of the inner being in terms of the professional language, the discourses they use to define the relationship and exert power over the patient. There are also less overt discourses which exist in terms of for instance, between partners, between teacher and pupil, between members of the family. Each of these may be used perhaps inappropriately in certain contexts and set up certain conditions that will influence the behaviour of the individuals concerned, by drawing upon relational language which will strongly influence the use of resources and approach which is possible to take.
For an approach to health to be successfully adopted that approach would need to be related to, whether compared, contrasted or otherwise evaluated against other existing forms of practice currently used and then take effect through being preferred in certain contexts to other existing approaches to health improvement. The process of integrating what could be classed as a new approach to health promotion would therefore involve discussion in, for instance practitioner journals, appraisals within organisations which have a responsibility for improving the health of the population and within training organisations that have a responsibility to deliver on training health professionals. The social aspects of evaluating an approach to health would need to be considered in order to assess the extent of the integration between fields and disciplines. Before the process of culturally embedding concepts in society can take place there appears to be a necessary stage of embedding approaches to health in practitioner circles in order to alter the practice of the professionals who deliver.
What could be seen to be taking place on several levels is professional conflict in terms of thrashing out what may be most beneficial about changing the manner in which health promotion practice is delivered and for discussion on this to be recognised as offering key indication of how professional practice will be changing. This does appear largely to take place in the form of indication from senior management within in- house journals regarding professional development issues, however, there does not tend to be a form of manual to state what degree of confidence staff may justly have in certain political actors. Use of macro, meso and micro levels of practice could highlight more readily what forms of political action to monitor in order to engage in work confidently and arguably staff should be trained in how to assess the likely changes which are to be implemented in the relatively near future, rather than there being a change resistant NHS that has materialised through inappropriate induction to the organisation.
What could be expanded upon in terms of Baric’s settings approach is use of discourse analysis and related methods of sociolinguistics in order to more boldly define the social environments and the quality of the organisational terrain. Furthermore, the approach that was developed may largely and inappropriately be classed as being a meso-level of social action, concerned largely with impacts on an organisational level, rather than on the level of an individual, that is a micro level, or on a broader level, a more strategic macro-level.
The process of embedding concepts in society as a means to improving health may require some debate in order to highlight some ethical issues regarding the approach concerned. There is also more to this that just using the concepts alongside others in order to indicate favour as discourse analysis may indicate. The assumption that health information is not damaging and does automatically lead to improvements in health and well-being is frequently challenged and may be effective for certain sections of the population, the middle and upper classes who would readily respond to health advice and information, and damaging to other sections, who may be described as more working class, less responsive to changing behaviour patterns and ‘culture’ and more likely to reject heath information as disempowering or state controlled propaganda rather that acknowledging the potential benefits that may take place through adopting healthier lifestyles. Culturally embedding a concept may lead in the short term to improvements for the middle and upper class sections of the population and some negative impacts for the lower socio-economic groups concerned. What would be necessary in this instance is examination of how social change takes place across a number of levels of society according to socio-economic group. Research examining social change on stated socio-economic levels of society may have been called upon in the past in a relatively constant manner in order to avoid problems related to the need to examine cultures within a society and how social groups may differ greatly in terms of how they change. Examination of this and whether or not this could be classed as relatively successful should be undertaken on a regular basis in order to justify the manner resources are distributed on research concerning health and behaviour change.
The use of macro, meso and micro levels of action to define health promotion activity may have its benefits in terms of positioning a wide range of action that is geared towards improving the health of a population. It may assist practitioners who deal with the public to be able to view the context of their action in a broader strategic framework. Arguably, this may already take place however a bolder and clearer context for this to take place within may offer some benefits to practice. Utilising the levels of macro, meso and micro may also assist in identifying some of the potential areas for change in health promotion practice and offer a clearer rationale for how and why health promotion work is coordinated within a locality. As stated arguably, much of this will already be dealt with in middle and lower levels of management, however, there could be potential clarity to the role of health promotion worker by developing a broader model of health promotion practice which encompasses models of social and individual change on several levels simultaneously. There is also a question regarding the methods used to generate social change within health promotion practice and there could well be potentially enough in terms of activity in research already to determine questions about the processes of socially embedding an issues to lead to health gains. Various methods of social research may shed light on this issue and publication of a volume which indicates this may be beneficial to practitioners in the near future.
I would have to state that I have limited knowledge of the current NHS proposals for change and much of this that is stated may be a number of years out of date. There are a number of questions in my mind regarding the use of discourse analysis as a research tool that tends not to always deliver what it may be presented as being able to offer. The successes of discourse analysis from the one research project I undertook tended to give indication that the quality of analysis rests mainly upon having selected texts, that is language to examine and explore, that will highlight key points regarding the nature of the social environment. As a result I would encourage Directors of Public Health to consider the potential of the methodology as one of several resources available to explore the political environment in which they operate.
The degree of sensitivity to language use in has perhaps increased with the advent of political correctness and through civil rights movements concerning race and gender and some forms of discourse analysis may already be integrated into professional practice to a degree already. Norman Fairclough, an academic whose work has concerned the implementation of discourse analysis in a number of fields, makes several points of this nature in his texts on discourse analysis, particularly in relation to conventional manners, where someone well mannered will socially construct other people in a style which reflects positive qualities and may challenge negative implications of comments made about them in an assertive manner. To have no awareness of some of the main methods of discourse analysis may be very difficult for anyone in professional practice.
In some respects the notion of dividing public health practice in to macro, meso and micro levels of action may not offer any significant improvements as this type of structuring of health practice can occasionally be devisive and lead to unnecessary and unbeneficial conflict between professional groups. There are benefits perceived by a number of local government bodies which have to a degree maintained the interest in healthy cities as an initiative over a number of years and the structure added by using the WHO accredited approach has been of benefit to several cities. Arguably, there may not need to be more insignificant change and re-labeling of practice in order to satisfy academic whims.
There are other issue areas that strike me as being relevant to explore and one of these concerns the vast amount of literature that I collected on networks and partnerships. There is literature from a number of professional fields which may be worth exploring in terms of health promotion practice and perhaps formal contributions from health promotion on the literature may illuminate issues useful to trans-disciplinary professionals. Networks as a concept related to social interaction between stakeholders concerned with a particular issue have been studied and conceptualised on a number of levels and concepts of networks may provide some means of improving health promotion practice. There is a strong element of concern over the validity of exploring this type of issue when there is perhaps not strong enough interest in the academic contributions made through the research that has been undertaken. Is the literature on networks and partnerships of the least degree of relevance to health promotion practice?
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