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Propitious readings for a health promoter

Jan E. Ritchie, University of New South Wales, Australia

What a sobering task!  When one is asked to consider which five resources have been most influential in more than forty years of health professional practice, it takes thoughtful reflection over quite some days to come up with an answer.  In the end, I have chosen five that definitely have made a strong impact on me, but I have to admit there are others that have been equally as influential.

‘A contribution to the philosophy of medicine …’

I began my health promotion work in clinical settings where the clinician’s word was law.  In the ’50s, and ’60s, patients, clients and community members were given instructions and were expected to comply.  Not to comply resulted in them being branded ‘difficult’ – an early version of victim-blaming, I guess.  I was very uncomfortable with this way of working but found no models to suggest there could be a different way to work until I came across the classic paper by Szasz and Hollender (1956).

Szasz and Hollender suggested, all that time ago, that there were three models of relationships between patients and practitioners. The first they called the ‘model of activity-passivity’ where the all-knowing and all-powerful practitioner administered to the submissive, non-contributing patient.  Here, they explained, the power balance was squarely on the side of the expert professional.  A second model they termed ‘the model of guidance-cooperation’.  In this approach, patients were expected to cooperate and acquiesce to the extent that they concurred with the advice of the practitioner and approved of the power being held by the latter.  Szasz and Hollender called their third model the ‘model of mutual participation’.  They reasoned that this was their model of choice in that equality among humans is desirable and that working in this way could prove satisfying to both parties.

The influence of this paper on my practice was enormous.  I decided that I too believed this was the model of choice for my work.  I enrolled myself in training to learn facilitating skills to engage with my patients in ways that allowed them to exert options.  Oddly enough, one of the really interesting things that I learned through applying these skills was that not all individuals want to retain power over their health outcomes.  Some people take great comfort in relinquishing power, particularly less-resourced individuals who have little power over other aspects of their life, and it is up to us to recognise when this is the case.

‘Most human behaviour is learned (created) observationally through modelling.’

Following the development of an interest in power relationships, I continued to work in clinical settings where I started to explore the educational aspects of practitioner-patient relationships.  I found the work of Albert Bandura fascinating.  Thus I arrived at another watershed in my career created through my readings.  Whereas I had only been exposed to didactic methods of patient education up to that point, I started to inquire into alternative teaching and learning approaches.  Making learning interesting, stimulating and above all, enjoyable, became my aim.  Whereas Szasz and Hollender had assisted my adoption of new values, Bandura’s 1977 book contributed to my understanding and application of actual skills in health education.  I explored such aspects as group learning and peer support, and harnessed opportunistic and informal learning situations for the benefit of the people with whom I was working.

‘The determinants of incidence are not necessarily the same as the causes of cases’.

As my focus moved from individual patient education to community-wide health promotion, I began absorbing public health principles for conveying health messages across whole populations.  At this stage of my career, I was in danger of becoming a killjoy, exhorting everyone around me to give up virtually all the pleasures of day-to-day living in the interests of longevity!  Geoffrey Rose’s marvellous essay on ‘Sick individuals and sick populations’ (1985) stopped me in my tracks and brought me to the realisation that what may be aetiologically the problem for a whole population does not convert to be so for all individuals within that population.  Risk factors are associations, not causes.  Their presence indicates a greater probability of succumbing to a specific disease, but many individuals in whom the risk factor is present do not succumb.  My most valuable learning from this paper was that promoting health by trying to reduce risk factors through voluntary behaviour change was substantially limited in scope, and might not be the most useful way to proceed.  What better way forward was there?

‘ … making the healthier choice the easier choice’.

As I was asking these questions, I moved from a practitioner role to an academic one.  Despite my role change, I was now teaching and researching what I had previously been practising, so the issues did not go away.  In fact the importance of the questions was magnified since these same questions were also being asked by my students.  The answer came with the release of the Ottawa Charter for Health Promotion (WHO 1986) heralding the beginning of the ‘new public health’ movement.  Visitors to this Website will not need to be enlightened as to the contents of this document, but to me in the mid-to-late 1980s, the Charter was a revelation.  Not only was it acknowledging that my misgivings about narrow risk factor reduction were shared by others, it was also giving me answers to my question regarding what better approach might be able to be harnessed.  The Charter’s action orientation was generally appealing but the part that really provided the watershed for me here was the raising of the potential for promoting health through building healthy public policy.  Instead of the frustrations I had experienced in working only with individuals, I was here being encouraged to work as well with policy makers who were in positions where they could act to change structures in society.  What was more, my earlier beliefs about working in mutual participation were being reinforced in that the Charter was indicating that the best outcomes were those that enabled people to make healthy choices rather than expecting individuals to do as they were told.  I avidly read everything I could lay my hands on that was written by those associated with the birth of the Charter, so that well-thumbed papers by authors such as Ilona Kickbusch and Trevor Hancock were always to be found at the top of my readings in my office.

‘… the unfortunate belief that “human survival is independent of nature”.’

In seeking to work over the last fifteen years from the socio-ecological perspective of the new public health movement, I have become more and more convinced that health promotion should be proactive in creating and investing in optimal conditions for health rather than reactively dealing with problems that are already in train.  At this turn of the century, I have come to the realisation that we need to be promoting health globally.  I basically believe that ultimately the health of human beings is dependent upon the health of the global environment.  Within this frame of mind, I have been most excited to be introduced recently to a discussion document by Soskolne and Bertollini (1998) arising from an international workshop on environment and health held in Rome in 1998.  What makes this document exciting for me is that the authors use the most compelling language to put the case for ‘global change becoming an issue for public health involvement’.  They use terms like ‘life-support systems’ to refer very graphically, not to the familiar usage of artificially sustaining the life of an individual, but to biophysical functions that sustain life of all of us on Earth.  They quietly yet convincingly critique what I call the ‘irrationalism’ which underlies most of the economic policies pursued by the world’s nations.  They vividly portray the difference in meaning between growth and development in the analogy of a cancerous tumour which gets bigger (growth) without getting better (development) and suggest that most policies are leading us into a state with characteristics of the former instead of the latter.

The call to action from Soskolne and Bertollini, for public health personnel to act now, is a challenge which is both frightening yet inspiring.  I know that for me, their discussion paper is yet another watershed document which has served to confirm and take forward my beliefs and actions in a way that can only enhance and strengthen the direction my career is taking.

References

1. Bandura, A. (1977). Social Learning Theory. Prentice Hall NJ. WWW

2. Rose, G. (1985). Sick individuals and sick populations, International Journal of Epidemiology, Vol 14(1): 32-38. WWW

3. Szasz, T. and Hollender, M. (1956). A contribution to the philosophy of medicine:the basic models of the doctor-patient relationship, Archives of Internal Medicine, Vol 97: 585-592. WWW

4. Soskolne, C. and Bertollini, R. (1998). Global Ecological Integrity and ‘Sustainable Development’: Cornerstones of Public Health, based on an Internationsl Workshop at the WHO European Centre for Environment and Health, Rome Division, Rome Italy, 3-4 December. WWW

5. WHO (1986). The Ottawa Charter for Health Promotion. Proceedings of the First International Health Promotion Conference, WHO, Geneva. Or Website WWW

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