Health Promotion Theory:Contributions from Wayne Parsons Public Policy.

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?

The walk to school - could motorists make greater effort to ensure the walk to school is safe?

Like most children in the 1970’s I used to walk to school. I was more or less limited to do this because my parents didn’t have a car and while it was only a fifteen minute walk I would have liked the option. What has become common place and entered our culture is the notion of the ‘school run’ in the ‘chelsea tractor’ - driving the kids to school is the means of ensuring that they reach the destination.

I don’t know to what extent it is classed as a problem for the most of the population however, I do regard this as a significant problem of the times. Not only because of the impacts upon the children themselves in terms of evidence of preteens coronary atherosclerosis, or heart disease in under 12s. But also because there are major impacts upon the environment as a result of the increases in traffic and the speed that the extra traffic travels at as a result of congestion. There are other areas of impacts as well, this must make some difference to a child’s awareness of local space and willingness to walk on other journeys as well.

In some areas I have been witness to motorists who will do what is necessary to ensure that the trip to school is safe who intervene in fighting or bullying when it takes place on the journey to or from schoo. If this does not take place there is greater chance that there will be a decision made by parents to take their kids to school themselves.

This may take the form of bibbing a vehicle horn at any group of youths who appear not to be conducting themselves in a way that is generally going to be classed as acceptable. It may also require some greater intervention to stop and challenge what seems like very undesirable behaviour. This could of course cause some concern or excessive noise on occasion but is it worth making some effort to do this on balance? There is also the more recent change that there are going to be camera phones and other recording equipment carried by motorists and if pupils are in school uniform, as a result easily identified on the walk to school, they may find when they reach school there are emailed copies of the events that have taken place on the way to school.

There may be a degree of distrust in society at large at present but surely collective action can ensure that the overall trend does not continue and may reverse?

Offering advice to 'the paranoid' – being on the other side of the adviceworkers desk.

It is fourteen years since I worked at the Devonport CAB with the other individuals who had the drive to deliver a service that would help the Devonport locals deal with the problems they had. It may help to characterise the period by describing the political context of the time before discussing the issues that I wanted to raise. There was an almost nonchalant right wing government that may have been possibly so little concerned with the bottom 10% of earners in the public that they damaged Conservatism irreparably. There were the major events of the Poll Tax riots and the riots at the protests over the end of student grants. And, although there was the launch of Heseltine’s urban regeneration initiative there were strong signals from central government that the areas that experienced multiple-deprivation somehow didn’t matter. I was influenced to undertake the role of CAB advice worker because of the Maoist philosopher & Newcastle Brown Ale drinker – Tim Moss, who encouraged the action of voluntary work in deprived urban areas which isn’t quite as dramatic an undertaking as doing voluntary work overseas in some far off land to most people, though need may be great in deprived urban Britain. There was a tendency back then to elect left wing local councils as a reaction to the right wing central government as perhaps there may currently be a tendency to elect right wing councils in order to give a message to left-wing central government.

It wasn’t my first job but delivering CAB Advice Work was the first work I made a serious attempt at engaging in employment since I’d graduated a year or so before. Before that I’d been involved in various service delivery jobs and not been able to do what any of my education was geared towards. I did find it quite a difficult transition to make - I guess I’d spent too much of my teens loafing. There was a degree of conviction that is not uncommon in the voluntary sector all over the UK within Devonport CAB’s team. Ironically, I had ongoing issues with depression and no real diagnosis which attempted to deal with the matters which underlie the swift changes in mood that left me occasionally feeling very typically helpless.

The reason I write this blog relates to the experience I had when I saw at least two of clients who appeared to be reporting conspiratorial matters. I didn’t really know how to take them in relation to the issues they were raising - if anything I would have to offer some form of apology to the people I assumed only to have suffered from what appeared to be organically generated mental health problems. They appeared superficially at least to have completely unfounded allegations to make against the state, government, establishment or whatever forces of action may be present in the UK and I, rather than completely dismiss what they were stating, just escalated the case enquiry to a supervisor. I don’t think there was an aim to reduce the person making these allegations to a point where they felt that we weren’t willing to believe them but I don’t really feel that we did offer any major service on the matters that were likely to limit their lives.

The oddity of the situation, what I think feels very ironic is that I then several years later, is that I too entered a CAB regarding a matter which I think was, to them, wholly attributable to the likelihood that I was suffering with mental health problems. On the other side of the desk, what appears to be the case seems to be that there could be programmes of action against some members of the public that may not be part of the action of some longstanding tradition but because there are no clear links, evidence or motives they appear totally irrational, a reflection of illness. What can happen is that advice services are not strongly geared to do a great deal to assist people in this position and as a result even if there are intention to ensure that each member of the public is treated reasonably there isn’t a great deal that advice services can offer to someone who is in this position.

I may have been slightly honed by the influence of psychology and psychologists. Professionalism within psychology tends to mean not challenging the general assumptions within theory that the psychological professions have generated especially in relation to the notion that society may ‘cause’ some forms of mental illness – mental illness is the disease of the individual. There was always a suggestion from people in psychiatric training and who were linked to clinical psychology that it was not an area to question Policing as this is a professional group that may be called upon with exceptional cases with patients. Whilst this is not the type of matter that is challenged within academic psychology there are routes into this area. There is a journal of political psychology which is concerned more with the impacts upon politics of psychology rather than vice versa – and this is a matter which is regularly discussed by students and patients alike, however, there does not seem to be a strong enough debate on these matters within practitioner journals. Laid on top of that there is not

This and other ‘paranoid’ thoughts are in some ways easy to dismiss, though this can only appear to incriminate the advice service – maybe the politically correct response to someone who, to many may obviously have mental health problems, could be that we don’t have the facility to assist you, and that medical and legal frameworks do not appear to be suitable to address the matters that you’re raising. This of course could lead to greater dissatisfaction with the service that is available. There does seem to be a loophole that for instance the types of antics that go on in the film ‘Changing Lanes’ that could lead to a great deal of paranoia may not be that illegal, certainly not something that the Police would class as criminal harassment, and is not presently legislated against. Providing evidence of this type of action may be difficult to do as well considering the Police as servants of the ruling class actually investigating malpractice within workplaces that may otherwise not be considered as worthy of investigation. Perhaps a few well chosen cases to explore may result in costly delays to a business and result in such a deterrent to other businesses that there could be an incredibly strong counter culture against this type of instance occurring again. Paranoia may be worth reconceptualising from a number of professional perspectives considering the action that a service could take may shape what is or isn’t worth as conceptualising into a definition of paranoia.

It seemed that there weren’t necessarily matters that were related the thoughts of persistent risk and persecution only feeling that people were potentially threats – it consideration of these as being unlinked to data, theory or rationale which normally rings someone’s alarm bells that a person is really and truly mad. There is scope to assess risk and perhaps we have much stronger drives genetically to assess risk collectively and to form a culture to act on this than we acknowledge. When we lose this from our culture we maybe then start to malfunction – what a healthy individual has is access to this form of process and a meaningful link with it. This is evolutionary psychology in a form which is very closely linked to the foundations of the Ottawa Charter for health promotion. There could be very individual forms of risk assessment that are prevalent in our culture which may remain relatively healthy processes such as perceiving all motorists as a potential risk when motorcycling. When past the risk it is generally forgotten about, or at least no longer central in the mind of the rider. For someone with a mental heath problem their general perception of events becomes very unbalanced and recent risk events stay in the mind and are not left behind leaving clear focus. This is going a little Zen and the Art of Motorcycle Maintenance, but there does tend to be a need to continually assess risk more often than not alone. When dealing with the issues that cluster together that may be presented someone with a mental health problem may not able to prioritise, forget about issues which are likely to be fruitless and then deal methodically with those that are worth pursuing. They may also find that they can not interpret what someone is saying when trying to assist them and may continually become difficult to deal with. To a large extent I would imagine advocacy services may be expensive but necessary for people with this condition and I would hope that there would be services made available.

There are other features of the condition which are probably worth indicating but maybe are well covered elsewhere in the sites linked to support for people with mental health problems. I don’t think that I can really sum up much of what the condition has been like other than to state that it’s possible to cover up what feels like a living hell quite easily. I wish to describe the living details of what the mood disorder has been like – I do class people as being very lucky in some respects that they are connected to what is going on in their lives and that they are experiencing moods which are connected to the social events which are going on around them.

The general trend of reducing funding to psychiatric services and increasing police services may shift some responsibility onto Police Forces and PCSOs to deal more effectively with the preventative role they have in dealing with the situation. It becomes increasingly more and more important to consider the role of the Police along with other services in the prevention of mental illness. This may become an area for housing and policing officials to determine a research agenda for if current trends in service provision continue. There will be members of the public coming into advice service centres and stating that they think there are all manner of actions being undertaken against them – a proportion of which may be relatively accurate appraisals of influence which may limit someone’s quality of life. What advice are they likely to receive as part of conventional practice under the guidance of Mr. Brown will remain to be seen.

It was only a very few people that were subject to this type of allegation against the state government or of corruption although I don't know if that was NACABs classification or other reasons including avoiding staff dwelling on the illness state of the client group who were largely local. Having said that I have what appears to be very fractured recall of seeing several staff that I worked with during this period being grabbed and injected which is a little Jacobs Ladder but it’s unusual what I do seem to recall. I don’t know if this is highly creative memory but there does seem to be something that took place I can’t recall. I guess a major difference between being problematically mentally ill and having made a recovery is that I can at least get on with my life despite having unresolved recall of events.

As a final aside I vaguely recall there being some incidents with, I think, the group of grebos from the Cooperage. I assume that one of them was tipped off about some potential corruption and there was a low key attempt to ensure that people were informed about this years before the event – the event being the tsunami in 2004. In about 1993 or 1994, there was an attempt at low key publicity which was carried out, which appeared to be led by one of the grebos. On cardboard signage the terms ‘2004’ and ‘tsunami’ appeared at the bottom of Royal Parade outside petrol station for a couple of days. I don’t know if this was in relation to a computer which was named a ‘tsunami’ which was on the market before the South-East Asian tsunami of boxing day 2004 or not. Just because there was a tsunami in 2004 does not mean that it was linked to a corrupt process and there could have been a large number of predictions made of this nature which don’t appear to have any form of consolidating information to support them. I don’t know if anyone in Stonehouse witnessed this or made a record of what was on these rather odd cardboard signs, however, it would be interesting to find out exactly what was going on....this was the issue I was ignored by CAB staff in Birmingham over and it would be interesting if there were any records in Plymouth of what happened in the early 1990's