Health Promotion and Disease Prevention
’Imagination lights the fuse of possibility.’
This chapter focuses on the psychological dimensions of health promotion. Two contrasting approaches to health promotion are described: the behaviour change approach and the community development approach. Health promotion interventions informed by each approach are described and critically examined. Criteria for the evaluation of the effectiveness of health promotion interventions are also presented. We conclude with discussions concerning healthist discourses in health promotion and the latter’s wider implications on subject positioning and experience.
What is Health Promotion?
Health promotion is any event, process or activity that facilitates the protection or improvement of the health status of individuals, groups, communities or populations. The objective is to prolong life and to improve quality of life, that is, to prevent or reduce the effects of impaired physical and/or mental health in those individuals who are directly (e.g., patients) or indirectly (e.g., carers) affected. Health promotion practice is often shaped by how health is conceptualized. While early models focused primarily on disease prevention (as influenced by the biomedical model), more recent models are influenced by the biopsychosocial model, which takes into account the psychological and social determinants of health.
In 1986, the Ottawa Charter for Health Promotion defined health promotion as ’the process of enabling people to increase control over, and to improve, their health’ (World Health Organization, 1986: 1). The charter recognized that this process requires the strengthening of skills and capabilities of individuals, communities and social groups. This involves building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills and reorienting health services. The Ottawa Charter also acknowledged that health is a resource for everyday life, not the object for living. It affirmed that the prerequisites for this state of well-being should include peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. To achieve its goals, health promotion needs to: (1) advocate for health and create favourable social conditions; (2) enable individuals to achieve their fullest health potential by reducing inequalities and ensuring equal opportunities; and (3) mediate between all sectors of society and coordinate with people from all walks of life. A weighty agenda indeed!
Health psychologists can be involved in health promotion in different ways. There are specialists who have expertise on developing behaviour change techniques, while there are those who work within communities and provide support to other professionals in the health and social care arena (Lawrence and Barker, 2016). In this chapter, we present two commonly used approaches to health promotion: the behaviour change approach and the community development approach. While these approaches pursue different goals, utilize different means to achieve the goals and propose different criteria for evaluation, both aim to promote good health and to prevent or reduce the effects of ill health. Health promotion interventions informed by each approach are described and critically examined.
Behaviour Change Approach
The goal of the behaviour change approach is to bring about changes in individual behaviour through changes in their cognitions. Based on the assumption that humans are rational decision-makers, this approach relies heavily upon the provision of information about risks and benefits of certain behaviours. As such, this approach to health promotion is synonymous with health education as it aims to increase individuals’ knowledge about the causes of health and illness. Health information can be disseminated through leaflets, mass and social media campaigns, visual displays or one-to-one advice. Information is often presented as factual and attributed to an expert source. Health messages can be framed positively by highlighting the benefits of the behaviour, or negatively by emphasizing health risks (see Chapter 14). Through the provision of health information, this approach gives the illusion of patient empowerment by enabling individuals to make informed choices and to allow them to take more responsibility for their own health.
Social Cognition Models and Behaviour Change
As we saw in Chapter 8, theories about the relationship between knowledge, attitudes and behaviour are known as social cognition models (SCMs). These have been researched in a wide range of preventive health behaviours, such as vaccination uptake, breast self-examination and contraceptive use. SCMs aim to predict the performance of behaviours and, by implication, to provide guidance as to how to facilitate their uptake by manipulating relevant variables (such as beliefs, attitudes and perceptions). A systematic review has shown that published interventions that aim to explain behaviour change and maintenance tend to focus mainly on motivation, self-regulation, resources, habits and social influences (Kwasnicka et al., 2016). It is suggested that there is a close relationship between people’s beliefs, attitudes and their intentions to act in particular ways. Consequently, by bringing about changes in knowledge and beliefs, it is hoped to bring about behaviour change. Now that sounds as easy as falling off a log, but is it really?
To give an example, Cassidy et al. (2014) used the health belief model (HBM; Becker, 1974) to design an information-based intervention to promote HPV vaccine uptake. A brochure was given to parents of pre-teen girls, and electronic alerts promoted telephone reminders for dose completion. Using a quasi-experimental design to evaluate outcomes, results showed that parents who received the intervention were 9.4 times more likely to have HPV vaccine uptake and 22.5 times more likely to complete the dose. If these kind of outcomes could be obtained everywhere, that would be really exciting!
The theory of reasoned action (TRA; Fishbein and Ajzen, 1975) and its revised version, the theory of planned behaviour (TPB; Ajzen, 1985, 2002), have also been used extensively to predict health relevant behaviours and to use these as a framework to develop behaviour change interventions (see Chapter 8 for further details). For example, Giles et al. (2014) used the TPB to develop an intervention to improve young people’s motivations to breastfeed. PowerPoint slides developed by the Health Promotion Agency (Northern Ireland) were initially used in the programme. This was further developed using information from focus groups and questionnaires with young people exploring their cognitions around breastfeeding. The findings were integrated into the final intervention. This was delivered as part of the Year 10 Home Economics curriculum in the school. To evaluate outcomes, questionnaires that included key components of the TPB were administered to control and intervention schools. Findings showed that female pupils from the intervention group had increased intentions to breastfeed, improved their knowledge, and had more positive attitudes and perceptions of subjective norms towards breastfeeding than those in the control group. The only trouble is we never know whether those good intentions will cash out in actual behaviour, as quite frequently they do not. This is known as the ’intention—behaviour’ gap. In a systematic review, McDermott et al. (2016) found that although some behaviour change techniques had positive effects on intention, these did not have an impact on behaviour.
Theoretical developments in the use of SCMs to predict health-relevant behaviours have also seen extensions of existing models by incorporating additional variables (see Chapter 8). For example, Rogers’ (1975) protection motivation theory expanded upon the HBM to include the role of fear in promoting behaviour intentions. This model had been influential in the use of fear tactics in persuading people to modify behaviours. One example is the use of graphic warnings in anti-smoking campaigns.
Ruiter et al. (2014) reviewed 60 years of fear appeal research and concluded that fear tactics may not be the most appropriate strategy to promote healthy behaviour. Presenting coping information that increases perceptions of response effectiveness may be more effective than presenting fear-arousing stimuli. Ethical issues also must be taken into consideration when using fear-arousing stimuli in health communication. Brown and Whiting (2014) argued that the use of fear tactics poses the potential risk of harming audiences who do not consent to being exposed to these campaigns and are unable to withdraw from them. Gagnon et al. (2010) also argued that the use of fear can be understood as society’s way of managing citizens’ behaviours. Drawing upon Foucault’s concept of ’governmentality’, the authors critically analysed a sexual health campaign, ’Condoms: They aren’t a luxury’, and examined how young adults are encouraged to ’consume’ fear and to practise self-discipline to avoid suffering the adverse consequences of unsafe sex. The authors were concerned that ’young adults are more likely to capture the undertow of the prevention campaign and internalize the invisible messages — hereby referring to the discourses of punishment and moral disgrace surrounding STIs and those who contract them’ (Gagnon et al., 2010: 253).
This resonates with Lupton’s (1995) critique of the discourse of risk prevalent in contemporary health promotion. She proposed that ’risk, in contemporary societies, has come to replace the old-fashioned (and in modern secular societies now largely discredited) notion of sin’ (Lupton, 1995: 89). This is achieved through the practice of health risk appraisals and screening programmes. Lupton likened these practices to religious confessions where sins are confessed, judgement is passed and penance is expected. Lupton pointed out that risk discourse attributes ill health to personal characteristics such as lack of will power, laziness or moral weakness. In this way, those ’at risk’ become ’risk takers’ who are responsible for their own ill health as well as its effects upon others and society as a whole. Lupton argued that risk discourse can have detrimental consequences for those positioned within it: being labelled at risk can become a self-fulfilling prophecy since people may feel reluctant to seek medical advice for fear of being reprimanded. Also, it can give rise to fatalism, as well as anxiety, uncertainty and fear, as, for example, for women ’at risk’ of breast cancer who can experience their ’at risk’ status as a half-way house between health and illness (Gifford, 1986, cited in Lupton, 1995).
Despite the risks and criticisms associated with the use of fear tactics in health promotion, several campaigns still adopt this approach to influence behaviour change. To explore the reasons for the wide application of fear appeals in health risk communication, Peters et al. (2014) conducted semi-structured interviews with 33 stakeholders in behaviour change interventions in the Netherlands. The analysis suggested that the main reasons for using fear arousal were to attract attention and to encourage audiences to reflect about risks. Social dynamics and power structures in intervention development play a role. While those who were more closely involved in developing and implementing interventions were convinced that fear arousal should be avoided, often they were unable to convince funders, who preferred the use of fear appeals in health risk communication. Furthermore, non-researchers were unable to understand the research evidence about the use of fear tactics and the cognitive processes involved in behaviour change. The psychologist must learn the best ways to communicate evidence to programme investors in a convincing fashion, otherwise there can be conflicts.
Critique of Behaviour Change Approaches to Health Promotion
The behaviour change approach has attracted many criticisms. First, it is unable to target the major causes of ill health. Individual behaviour change, even when successfully implemented, cannot address socio-economic factors such as poverty, unemployment or environmental pollution. Its objective is change within the individual rather than change in the individual’s environment. Neglecting wider determinants of health poses the risk of generating further inequalities in health. As discussed in Chapter 4, there is an association between unhealthy behaviours and socio-economic status (SES). It can be argued that this can be explained by a wider intention—behaviour gap among lower SES groups. However, there is no evidence to support this. In a meta-analytic review of five studies, Vasiljevic et al. (2016) found that the intention—behaviour gap did not vary with deprivation on health behaviours such as diet, exercise or medication adherence in smoking cessation. However, there was a significant gap between self-efficacy and behaviour in more deprived groups. This implies that improving self-efficacy would be needed to promote healthier behaviours in lower SES groups. This can be achieved by developing individual-level interventions and more widely in community-level contexts through participation, capacity building and empowerment.
Second, the choice of which behaviour to target lies with ’experts’ whose task it is to communicate and justify this choice to the public. As a result, recommendations and advice provided ’from above’ can be seen as incompatible with community norms. Receiving health advice in a top-down fashion can be disempowering, as Ayo (2012: 104) argued:
Health promotion messages such as ’be active’, ’eat healthy’ and ’lose weight’, are boisterously propagated throughout Western neoliberal societies as the panacea to modern day health concerns of chronic diseases. Under this logic, it is individuals who are placed at the centre of health promotion strategies, as opposed to overarching social systems that also determine health outcomes. They are seen as being both the cause and the solution to potential health problems and thus are made to be accountable for their own health. However, when exercising one’s autonomy and freedom, it is expected that the responsible citizen will allow his or her lifestyle to be guided under the auspices of knowledgeable experts and normative prescriptions of what it means to be healthy. This requires attending to one’s own health in ways which have been socially approved and politically sanctioned.
Third, the behaviour change paradigm does not address the many variables other than cognitions that influence human actions. Despite the increasing range and complexity of SCMs, there are a number of shared characteristics on which to base a critique of the genre. For example, SCMs conceptualize the individual as a rational decision-maker and are only concerned with conscious, cognitively mediated health behaviours (e.g., the decision to buy a smoke alarm). However, many health habits occur routinely (e.g., brushing one’s teeth in the morning) and do not involve conscious decision-making.
Furthermore, with one notable exception that makes a questionable use of fear (protection motivation theory), SCMs generally do not take the role of impulse and/or emotion into account. Even where models do include the variable of ’volitional control’ (e.g., TPB; Ajzen, 1985), this is conceptualized as a conscious belief (in one’s own efficacy) that the individual includes in his/her rational appraisal. However, emotional needs and ’urges’ as well as power relations can have a strong and direct influence on behaviours. Consider as one example the deeply felt cravings of the quitting smoker or heroin user.
SCMs also assume that the same variables are universally relevant to diverse groups of people. The behaviour change paradigm tends to assume homogeneity among the receivers of its health messages. However, information is not received or processed uniformly by those to whom it is directed: mood, motivation, past experience, interest, perceived relevance, lay beliefs, group membership and many other factors mediate the way in which a message is ’heard’ and interpreted. Translating and communicating information in a meaningful way is a complex undertaking affected by a multiplicity of factors, including health literacy, the media and the ubiquity of health information (see Chapter 14). For example, Lawrence et al. (2016) demonstrated how training health and social care practitioners can support health behaviour change through open discovery questions, listening, reflecting and goal-setting. This approach is also cost-effective as it can be delivered using existing infrastructure. Creative methods, such as children’s story books, can also be used as a way to improve parental attitudes, intention and self-efficacy to promote oral health behaviour in their children (O’Malley et al., 2017).
Considering all of these criticisms, it is not surprising that outcomes from interventions based on SCMs are unimpressive, so much so that they show no significant improvements beyond those obtained with interventions lacking any theoretical basis whatsoever. As the authors of one study concluded: ’interventions based on Social Cognitive Theory or the Transtheoretical Model were similarly effective and no more effective than interventions not reporting a theory base’ (Prestwich et al., 2014). This is the disappointing legacy of half a century of research with SCMs. Alternative approaches need to be considered as the SCMs are quietly retired.
Community Development Approach
Health psychologists have explored different ways of understanding health and illness and engaged with different strategies for intervention with health and well-being. Throughout this book we emphasize the value of broadening the scope of health psychology by considering the social and cultural context within which health and illness are located and developing more socially collective strategies for promoting health. Recently, there has been increasing interest in the community development approach within health psychology.
The community development approach aims to improve and promote health by addressing socio-economic and environmental determinants of health within the community. These recognize the close relationship between individual health and its social and material contexts, which consequently become the target for change. Individuals act collectively in order to change their environment rather than themselves. Thus, it constitutes the interface between the environmental and the behavioural approaches to health promotion in that it is concerned with the ways in which collectivities can actively intervene to change their physical and social environment. The psychologist serves as an agent of change.
Over the past 20 years there has emerged increasing interest in developing a community health psychology. This has been defined as ’the theory and method of working with communities to combat disease and to promote health’ (Campbell and Murray, 2004: 187). As in community psychology itself, there are different orientations. The more accomodationist approach focuses on processes within the community, while the more critical approaches aim to connect intra-community processes with the broader socio-political context.
Theoretical Influences in Community Health Psychology
Community health psychology has deliberately attempted to connect with other developments in critical social and health psychology and with developments in community psychology. Paulo Freire’s (1910—1990) critical pedagogy is one of the key theoretical influences of this approach. Freire was a Brazilian educator who argued that the campaign to increase literacy was a political struggle. He contrasted the traditional approach to literacy education with a more critical approach. In the former approach, the all-knowledgeable educator pours her/his wisdom into the empty vessels, who are the students. ’Education thus becomes an act of depositing, in which the students are the depositories and the teacher is the depositor’ (Freire, 1970: 53). Freire described this as the ’banking’ model of education. In the more critical approach, the educator engages with the student in an active dialogical manner to encourage them to consider the broader social and structural restraints on their lives and how they can begin to challenge these through collective action.
Freire used the term conscientization to describe this process of developing critical consciousness. He stressed that his work was ’rooted in concrete situations’ and emphasized the collaborative nature of his work. He described the radical as someone who:
does not become the prisoner of a ’circle of certainty’ within which reality is also imprisoned. This person does not consider himself or herself the proprietor of history or of all people, or the liberator of the oppressed; but he or she does commit himself or herself, within history, to fight at their side. (Freire, 1970: 21)
These ideas were also developed further in the liberation psychology of Ignacio Martín-Baró (Box 17.1). While acknowledging Freire’s ideas as a powerful starting point for advocacy and community development, Campbell (2014) also encouraged contemporary community health psychologists to develop approaches suitable for new century problems.
Box 17.1 Liberation Psychology
This approach draws its inspiration from the liberation theology developed by the worker-priest movement in different countries in Latin America during the 1950s and 1960s. This movement argued that it was the duty of Catholics to fight against social injustice and to adopt a preferential option for the poor. These ideas were given wider currency within psychology by Ignacio Martín-Baró (1942—1989), who was murdered by the Salvadoran army for his campaigning work in defence of the poor.
He developed a form of liberation psychology that set as its primary task the interests of the poor and oppressed. He criticized mainstream psychology for its scientistic mimicry and its lack of an adequate epistemology (including positivism, individualism and ahistoricism). This focus on individualism ’ends up reinforcing the existing structures, because it ignores the reality of social structures and reduces all structural problems to personal problems’. Instead he argued that psychologists need to ’redesign our tools from the standpoint of the lives of our own people: from their sufferings, their aspirations, and their struggles’ (Martín-Baró, 1994: 25). He proposed three elements in this new liberation psychology:
1. A new horizon: psychology must stop focusing on itself and being concerned about its scientific and social status but rather focus on the needs of the masses.
2. A new epistemology: psychology needs to consider what psychosocial processes look like from the perspective of the dominated.
3. A new praxis: psychology needs to consider itself as ’an activity of transforming reality that will let us know not only about what is but also about what is not, by which we may try to orient ourselves toward what ought to be’ (Martín-Baró, 1994: 29).
Eliot Mishler states in the preface to the collection of his writings that they ’challenge us to align ourselves, as he did in El Salvador, with those struggling for equality and justice in our own country’ (Martín-Baró, 1994: xii). Cornish et al. (2014) proposed new ways of thinking about community mobilization by using the Occupy movement as an example (see Box 17.2). The authors argued that modernist conceptualizations of community mobilization tend to ’follow a linear logic, establishing a set of goals, objectives, indicators of success, and a clearly defined and hierarchical division of labour, with leaders on the top and frontline workers at the bottom’ (Cornish et al., 2014: 62). However, as reflected in many community-based health interventions, processes tend to be messier and less straightforward than planned. Thus, the authors encouraged community health psychologists to explore alternatives to instrumental rationality. They suggested to ’trust the process’ and to create mechanisms that enable people to decide on outcomes themselves. Creating a social space where people can come together for a common cause helped to develop a positive sense of community for Occupy participants (Permut, 2016).
Box 17.2 Using the Occupy Movement to Reconceptualize Community Mobilization
The Occupy movement is a global protest against corporate greed and the unjust distribution of economic and political power in society. It was inspired by the Indignados’ occupation of Madrid’s Sol Square in mid-May 2011. The movement gained vast media attention when Occupy Wall Street began on 17 September 2011. United by the slogan ’We are the 99%’, thousands of protesters camped in hundreds of cities around the world. On 15 October 2011, thousands gathered in London with the aim to occupy the London Stock Exchange (Figure 17.1). As the police blocked their access, the group settled and erected 250 tents in front of St Paul’s Cathedral instead. The protesters were evicted four months later. However, during the course of their ’occupation’, the group managed to establish a ’community’, with common facilities, networks and processes in place to organize themselves.
Figure 17.1 Protesters outside St Paul’s Cathedral in London
This is a concrete example of a process-focused community mobilization wherein goals were developed as part of a process rather than being imposed from above. This movement also reconceptualizes the notion of community wherein shared practices define what it means to be part of a community rather than by similarities of identity, interest or geographical location.
Source: Cornish et al. (2014)
More recently, important developments in South Africa and other countries have served to revitalize community psychology in terms of its socio-political project. This includes projects concerned with the health challenges faced by indigenous people and also the issues of colonialism and post-colonialism (Duncan et al., 2007). These developments have introduced important ideas, such as those of Frantz Fanon (2008). Fanon developed a sophisticated understanding of the psychology of political oppression, in particular the processes by which oppressed people internalize ideas of inferiority and worthlessness.
Another concept relevant to this approach is that of social capital, referring to the community’s ability to support empowerment through participation of local organizations and networks. Putnam (2000) discussed two kinds of social capital: bonding social capital, which refers to within-group social capital, and bridging social capital, which is concerned with linking with outside bodies with the power and resources to enable mutually interesting benefits to accrue. He argued that in modern society there has been a steady decline in social capital, which he characterized as the character of civic participation, trust in others and reciprocity within a community. Other work by Bourdieu has characterized social capital in terms of resources that can be drawn upon. In a systematic review, Samuel et al. (2014) explored social capital concepts related to health education and promotion. Trustworthiness, neighbourly reciprocity, reporting a good sense of community, neighbourhood collective efficacy and behavioural social norms were some of the concepts that were consistently associated with health promoting behaviours.
Promoting Healthy Behaviour and Well-Being in Communities
While the traditional focus of health psychology has been on promoting individual behaviour change, there have been various attempts to explore more community-based strategies. Previously, we have discussed how there have been various strategies designed to encourage behaviour change. However, these strategies have adopted the traditional individualist focus. Community health psychology attempts to work with groups or communities to identify how they see the issue and to explore opportunities for change.
For example, Hodgetts et al. (2014) worked in partnership with service providers and families living in poverty in Auckland. The project, Family 100, aimed to promote the social well-being of people in need by exploring the everyday lived experience of communities and how residents make sense of their experiences. The project involved exploration of topics central to poverty, including education, employment, housing, health, agency supports, income and debt, and social justice. Influenced by Simmel’s (1903/1964) principle of emergence of social phenomena, Family 100 assumed that wider systemic elements in society can be understood by exploring micro-level processes in community settings. By engaging community members in dialogue and by documenting these interactions, critical reflections were encouraged which were then used to form the basis for action. Thus, this approach repositions academic researchers into academic scholars (Murray, 2012b), whereby researchers work in collaboration with community members and other stakeholders to achieve change.
Community participation in health promotion can involve various community members in the process — it is not just about community leaders and activists. For example, Dela Llagas and Portus (2016) described how enabling farmers to develop their knowledge and skills to think, communicate, decide and act upon their knowledge can help to successfully promote actions on malarial control among marginalized rural communities in the Philippines. Nakiwala (2016) also demonstrated how children can be actively involved as partners in malaria education in Uganda. In this context, children acted as health messengers, and offered peer support and environmental management. This helped to boost the children’s knowledge about malaria, improved their self-esteem and developed their communication skills. Despite these positive outcomes, the programme also had its drawbacks due to hostility from some adults and time constraints due to tight school schedules.
Barbershops can also be used as a setting for health promotion. For example, in Phoenix, Arizona, Davis (2011) demonstrated how the barbershop can be used as a setting to improve health literacy and knowledge about the screening, treatment and control of high blood pressure among black barbershop owners and their clients. Barbers were trained by health care professionals to monitor and record customers’ blood pressure scores. They were also trained to identify customers with untreated hypertension and to be able to advise those who might need to seek further medical attention. Barbers were given information about blood pressure disparities within African-American communities and the impact of tobacco use on cardiovascular health so that they could inform their customers about these issues as well. The customers were offered ongoing monitoring every time they came to the barbershop, along with written information to supplement open discussions around hypertension, blood pressure and the screening process. In this innovative project, the barbershop was redefined as a social space where health messages could be communicated ’man to man’ in a supportive and engaging manner. This project illustrates how vital health information can be delivered in the community and in a culturally grounded manner that is accessible and appropriate to the target audience. In a systematic review, it has been shown that barbershop interventions have also been used to promote health education on prostate cancer screening. These interventions were generally well received by barbers and their customers, although health behaviours and outcomes have not been consistently monitored and evaluated (Luque et al., 2014).
Other contexts that can help to build social capital in the local community include playgroups (Strange et al., 2016), and ’Men’s Sheds’ which are community spaces that enable men to participate in a range of shared activities and interests in an inclusive and friendly environment (Wilson et al., 2016). It has been shown that social ties can be developed among Men’s Sheds users and can improve members’ physical, psychological and social health, as well as quality of life and willingness to accept health advice (Ford et al., 2015). Similarly, Camic et al. (2017) demonstrated how handling museum artefacts can be used to promote the well-being of people with dementia. The findings suggest that participants showed improvements in their well-being, particularly among those with early stage dementia.
Participation and community engagement are beneficial to both community members and researchers. A systematic review of the use of participatory methods in health research has shown that sustained community involvement enabled better identification of the components of complex interventions (Harris et al., 2016). The participatory research process also enables capacity building and participation among community members to take control of issues that impact on their lives (Mansyur et al., 2016). Social participation has also been associated with better physical health (Myroniuk and Anglewicz, 2015; Patel et al., 2016). In a systematic review, Smylie et al. (2016) explored the role of community participation in indigenous prenatal and infant and toddler health promotion programmes in Canada. Findings highlighted the importance of community investment, community ownership and high levels of sustained community participation and leadership, and how these are linked to positive outcomes, including birth outcomes, access to health services, prenatal street drug use, breastfeeding and nutrition, oral health, child exposure to Indigenous languages and cultures, and overall child development.
Combatting Structural Determinants of Health Inequalities
A more critical community health psychology attempts at all times to connect local action with broader social change. The extent to which community health psychologists make connections with the broader social context depends upon opportunity as well as orientation. Indeed, while community action projects can enthuse the participants, they are often apprehensive about taking wider social action. The magnitude of the task is apparent in the various community projects that have sought to challenge social inequalities in health.
In previous chapters we have outlined the substantial social inequalities in wealth and health that exist both within and between societies. As we have argued, the traditional individualistic lifestyle approach to addressing these inequalities has met with limited success. There is a need to address the material and wider social factors within which these unhealthy lifestyles are located.
Critique of Community Development Approaches to Health Promotion
It is clear that approaching health promotion using community health psychology as a framework is deeply political. It involves the collective organization of those who are traditionally excluded from decision-making processes and a direct and active challenge to power relations associated with health and illness. As a result, health promotion initiatives using this approach have the potential to come into conflict with interests that lie with the status quo, such as industry, employers, government departments and local councils that aim to make financial savings. Consequently, community action as a form of health promotion is vulnerable to lack of public funding and subject to resistance from dominant social groups (Stephens, 2014).
There is also a danger of ’professionalization creep’, whereby those involved in the initiative become removed from the grassroots concerns of those they set out to represent (Homans and Aggleton, 1988). Self-appointed community leaders or representatives can emerge who claim to speak for all members of the community but in reality represent the dominant elites. Alternatively, because of the huge personal effort and sacrifice needed to make this type of project work, professionals tend to become emotionally involved, which may lead to burn-out. Community change also occurs as a consequence of a complex interplay of actors, circumstances and actions. Generally, community workers have a strong commitment to social justice and may experience tensions when attempting to overcome challenges on the ground (Murray and Ziegler, 2015). The aims and objectives may well be noble and virtuous, but the consequences are not predictable or certain. The outcome could possibly be to the benefit of some and to the detriment of others in unpredictable ways (Estacio and Marks, 2010). When facilitating equitable community partnerships, researchers need to tread carefully. They need to be cautious of project ownership and not make community members feel ’used or over-researched’ (Matthew, 2017).
The notion of ’community’, upon which this approach depends, is problematic. For example, people who live in the same geographical space (or those who share a sexual preference, language, ethnic background, age group or social class) do not constitute homogeneous groups. The use of the term ’community’ obscures the diversity of lifestyles that exist within groups, posing the risk of failure to address the diverse needs of underserved members of a community.
While community-based methods are useful in surfacing local insights about health-related issues, these projects have been scrutinized for limited measurable outcomes when evaluating impact. Thus some systematic reviews have prompted the need for more high-quality randomized controlled trials with adequate statistical power to evaluate the effectiveness of community-based interventions (e.g., Amiri Farahani et al., 2015; Snijder et al., 2015).
The ability of an intervention to improve the health of individuals suffering from an illness needs to be evaluated if we are to place any confidence in the community psychology approach in health care. Ideally, a similar, robust level of proof is required for all types of intervention, as assumed in the evidence hierarchy (Chapter 7). However, there is an ’uneven playing field’ because the same high level of proof available for individual-level interventions is not feasible for community-level interventions. Individual-level interventions of the top-down variety can be studied in randomized controlled trials and the data can be synthesized in meta-analysis. This is because the parameters can be systematically varied in the design of any trial and the conditions controlled accordingly. Bottom-up community interventions are by definition unique to each particular community and circumstance, and the intervention(s) designed in light of the circumstances arising as the various stakeholders influence what actually happens.
A community intervention often feels very messy, fluid and difficult to control, and certainly not amenable to a randomized controlled trial. In fact, it is almost impossible to run trials using matched controlled conditions in bottom-up interventions of the kind reviewed here. When any intervention is truly bottom-up, there is hardly ever going to be the opportunity to provide a controlled evaluation. However, evaluation using other types of design is not precluded, and should ideally be carried out (e.g., processes and outcomes can be monitored and compared at different time points). Drawing upon Freire’s later work, the Pedagogy of Hope, Nolas (2014) encouraged community health psychologists to engage with the messiness of practice and argued for a ’journey’ approach to collective action. Since community health psychologists work with vulnerable groups and usually within multidisciplinary teams, it is important for the field to widen its research agenda and to be more open to interdisciplinary dialogue (Ferreira-Neto and Henriques, 2016). These have implications for the research choices we make, who we choose to work with and who remains neglected (Graham, 2017).
Health Promotion Evaluation
As discussed earlier, evaluation of the effectiveness of health promotion initiatives can be an extremely difficult undertaking. First, we need to differentiate between outcome evaluation, i.e., an assessment of changes brought about by the intervention, and process evaluation, i.e., an understanding of how and why the intervention worked. In addition, outcome evaluation can focus on a range of different criteria, such as behavioural (e.g., how many people have stopped smoking) or cognitive (e.g., the extent to which people’s knowledge about the health risks of smoking has increased) or health status (mental or physical). Furthermore, there may be unintended consequences of an intervention, such as increases in anxiety that may be generated by provision of information about particular risks.
In recent years, increasing emphasis has been placed upon evaluation and the need for evidence-based health promotion. Within a climate of financial pressures and budget cuts, public service expenditure needs to be cost-effective. Governments and funding bodies are more likely to invest in health promotion projects that can be shown to work. In addition, there are ethical reasons for systematic evaluations: ineffective or counter-productive interventions should not be repeated, while effective interventions should be made available as widely as possible.
Evaluation of health promotion interventions can be complex, as some interventions may require multiple components, involving several partners, contexts, target groups or behaviours. Datta and Petticrew (2013) examined the challenges described by researchers when evaluating such interventions. Using extracts from published journal articles (n = 207) from January 2002 to December 2011, the analysis suggests that the content and standardization of interventions, development of outcomes measures, and methods used for evaluation were common issues in evaluation. Challenges associated with organizational factors such as the impact of the people involved (i.e., staff and patients) and the organizational context were also described.
In the UK, the Medical Research Council (MRC) (2000, 2008) developed a framework for funders, developers and evaluators of complex interventions (see Figure 17.2). It recognized the complexity of developing and evaluating interventions and acknowledged that this process will require several phases which may not necessarily follow a linear sequence. While experimental designs are preferred, particularly randomized controlled trials, the MRC framework also acknowledged that using experimental designs may not always be feasible. Thus, alternatives have been proposed such as quasi-experimental and observational designs (Craig et al., 2013).
RE-AIM is another framework that can be used to evaluate health promotion interventions. Originally developed by Glasgow et al. (1999), the acronym stands for:
Reach — The absolute number, proportion and representativeness of individuals who participate in a given initiative, intervention or programme.
Effectiveness/Efficacy — The impact of an intervention on important outcomes, including potential negative effects, quality of life and economic outcomes.
Adoption — The absolute number, proportion and representativeness of settings and staff who are willing to initiate a programme or approve a policy.
Implementation (at the setting level) — How closely staff members follow the programme that the developers provide, including consistency of delivery as intended and the time and cost of the programme.
Maintenance (at the setting level) — The extent to which a programme or policy becomes part of the routine organizational practices and policies. At the individual level, this refers to the long-term effects of a programme on outcomes after six-month follow-up or more. (Source: www.re-aim.org)
The RE-AIM framework has been used for a wide range of health promotion interventions, including sugar-sweetened beverage interventions for children (Lane et al., 2016), older adult exercise programmes (Kohn et al., 2016), Type-2 diabetes primary care prevention (Sanchez et al., 2016), stroke research and education (Jenkins, 2016) and patient-centred fall prevention (Katsulis et al., 2016). More recently, it has been used to support the development of interventions and to translate research into practice. There are now over 100 publications that have used this framework.
As well as adopting a pluralistic approach to developing and evaluating interventions, evaluators need to be pragmatic by using data that can be realistically obtained yet remain meaningful and useful to the many key players in implementing the learning from evaluations. Often this is not an easy task. Failure to translate research evidence into practice and policy is not uncommon in clinical and health services (Grimshaw et al., 2012). Research evidence may not be accessible to practitioners and policy makers. It is also possible that practice is informed by other sources of knowledge apart from research (e.g., personal experience and interaction with others).
To bridge the evidence—practice gap, Klinner et al. (2014) recommended that conceptions of health promotion evidence need to be expanded. Furthermore, ’relationship-based’ methods need to be harnessed to enable practitioners to document community interactions and to use these as research evidence. This requires developing organizational capacity to enhance practitioners’ skills. Reforms in the research-to-practice pipeline are also needed to make research evidence more relevant and actionable in real-life contexts (Green, 2014).
Figure 17.2 Key elements of the development and evaluation process
Source: Craig et al. (2013: 589)
Challenging Healthism in Health Promotion
Health promotion is concerned with strategies for promoting health. It is assumed that (1) good health is a universally shared objective, (2) there is agreement on what being healthy means, and (3) there is a scientific consensus about which behaviours facilitate good health. From this perspective, the real (and only) challenge for health experts and educators is to find effective ways of helping people to maximize their health.
However, there have been criticisms of this contemporary ’ideology of health promotion’. In 1980, Crawford coined the term ’healthism’, which refers to the ideology that situates health and disease within the context of the individual. He raised concerns regarding how healthist ideas could lead to the ’medicalization of everyday life’ and reinforce neoliberal ideals by placing the emphasis on personal responsibility for health (see Chapter 4 for further critique of the ideology of the ’responsible consumer’).
Evans (1988) argued that such an ideology can also begin to drive health promotion interventions that instead ought to be informed by scientific evidence (both biomedical and psychosocial). Evans drew attention to programmes directed at lifestyle changes that are not unequivocally justified by biomedical research evidence, such as the recommendation to reduce cholesterol levels in the blood to prevent heart disease. Evans worried that ’by increasingly promoting presumably non-risky behaviours, we may be contributing to a type of mass hypochondriasis resulting in an increasingly diminished freedom in human lifestyle and quality of life’ (Evans, 1988: 207). This, he suggested, can result in an unhealthy obsession with exercise, an inability to enjoy a meal, as well as a reduction in spontaneity of lifestyle.
Recent critics of the healthist ideology draw upon critical theory to highlight how healthism is propagated in society and how this is used as a method of social control. For example, using critical discourse analysis and Bourdieu’s theoretical framework, Lee and Macdonald (2010) explored how healthist discourses are maintained through young people’s experiences in school physical education (PE). They interviewed rural young women and examined these alongside discourses from their school PE head of department (HOD). The analysis suggests that healthist discourses were evident in the way the participants discussed physical activity, health, fitness and their bodies. Health and fitness were constructed as important elements that enable them to control body shape and to conform to the ’ideal’ feminine appearance. Furthermore, findings suggest that the school’s PE curriculum is also being influenced by the HOD’s own engagement with healthist discourses and that these too impact upon young people’s understandings of health, wellness and their bodies.
The adoption of healthist ideas can also support and maintain social segregation. For example, Gurrieri et al. (2013) examined the impact of healthism-based campaigns on how women’s bodies are portrayed, and its implications on subject positioning and experience. Drawing upon embodiment theory, the authors argued that some health promotion campaigns (e.g., breastfeeding, weight management and physical activity) may inadvertently construct women’s bodies as sites of control. Using critical visual analysis, the authors showed that such campaigns can represent certain body types as less acceptable. Women who do not fit within the ideal body type or those who engage in activities that counter dominant health messages can become subject to stigmatization and exclusion. Thus the authors urged the emerging field of critical social marketing to develop a broader social justice agenda to address the societal impacts of health promotion campaigns.
Similarly, Barker-Ruchti et al. (2013) interviewed second-generation girls of immigrant background in Switzerland and examined how participants drew upon healthist ideologies to construct sport as a way to achieve good health and the ideal, feminine body. While alternative discursive resources exist, the authors found that the participants did not use these. It was argued that the use of healthist discourses provided participants with a way to construct their position as being integrated with Western knowledge and cultures, thus maintaining predominantly white healthist ideas and contributing to the promotion of the ’othering’ of foreign migrants.
Graham et al. (2015) explored the understanding of health among lesbian, gay, bisexual, pansexual, queer and transgender individuals in Aoteraroa/New Zealand. Twelve focus groups with 47 participants were held. Findings suggest that the participants also drew upon notions of healthism, such that health was perceived as holistic and that contextual factors created health risks. There is also a consistent view about the need to preserve health and how health promotion and education efforts are geared towards this purpose.
While healthist ideas can be used as a form of social control, Ayo (2012) argued that in the context of modern neoliberalism, healthism is shaping individuals into health-conscious citizens who willingly abide by society’s prescribed norms. Healthy lifestyles are now ’being sold’ by health promotion campaigners and other private companies wherein the responsible consumer is expected to buy into this lifestyle in the free market. Thus, social control is no longer constructed as something that is delivered forcefully. Rather, autonomous individuals wilfully obey the state and regulate their own behaviour as ’good and responsible citizens’.
Healthist ideas in health promotion have not gone unchallenged, however. Recent publications have explored the function and position of contemporary health promotion in an attempt to formulate alternatives to individualistic risk-based approaches (e.g., Stephens, 2008). Debates concerning the use of healthist ideas to promote neoliberal agendas have also sparked discussions and research into the politics of health promotion. For example, Lovell et al. (2014) examined how political changes have impacted on health promotion in New Zealand. They conducted interviews and focus groups with health promotion practitioners between January 2008 and March 2009. While neoliberal reforms have been adopted to increase efficiency in the health care sector, participants from this study have responded critically to government restrictions. In the face of limited resources and budget constraints, health promotion practitioners often have become community advocates when neoliberal agendas come into conflict with community priorities. In this respect, it is important for health promotion developers and practitioners to reflect upon their position and on how their work impacts upon the lived experiences of individuals and on society as a whole. Health promotion that is guided by evidence, ethics and values may be a good way forward (Carter, 2011). Otherwise, the healthist agenda could become yet one more mechanism for the creation of stigma, difference and discrimination.
1. Further development of critical social marketing is needed to encourage more discussion and consideration of wider social determinants of health in social marketing-based health promotion interventions.
2. Methodological developments in community-based research are needed to generate more robust evidence into the impact of community health promotion interventions.
3. Exploration of reforms is needed to encourage effective translation of research evidence into practice.
1. Health promotion is any event, process or activity that facilitates the protection or improvement of the health status of individuals, groups, communities or populations.
2. Two commonly used approaches in health promotion are the behaviour change approach and the community development approach. Each pursues different goals, utilizes different means to achieve its goals and proposes different criteria for intervention evaluation.
3. The behaviour change approach aims to bring about changes in individual behaviour through changes in the individual’s cognitions. Social cognition models are utilized in order to make the link between knowledge, attitudes and behaviour. However, attempts by SCMs to predict behaviour on the basis of cognitions has led to disappointing results.
4. Criticisms of the behaviour change approach include its inability to target socio-economic causes of ill health, its top-down approach to education, its exclusive focus upon cognitions, its assumption of homogeneity among receivers of health messages and its individualism.
5. The community development approach recognizes the close relationship between individual health and socio-economic factors. It aims to remove the socio-economic and environmental causes of ill health through the collective organization of members of the community.
6. Health promotion interventions that use the community development approach can encounter a number of difficulties. They can come into conflict with powerful bodies and they are vulnerable to lack of public funding and official opposition. Other problems include creeping professionalization and difficulties associated with defining and identifying communities.
7. Evaluation of the processes and outcomes of health promotion interventions can be a complex task as interventions may involve multiple components, involving several partners, contexts, target groups or behaviours.
8. Healthist discourses have sparked discussions concerning their role in social governance and control. It is important for health promotion developers and practitioners to reflect upon their values and the impact of their work on the lived experiences of individuals and on society as a whole.