RHP&EO is the electronic journal of the International
Union for Health Promotion and Education
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What are my five favorite resources as an Estonian health promoter?Anu Kasmel, MD., MSSc., Estonian Union for Health Promotion, Estonia. Kasmel, A. What are my five favorite resources as an Estonian health promoter? Reviews of Health Promotion and Education Online, 2004. URL: 10/index.htm. IntroductionComing from a clinical medicine background, it was quite challenging and exciting to be appointed as the director of a newly created national centre for health promotion in Tallin, Estonia, shortly after my small Baltic country got back its independence from the former USSR. This experience offered an extraordinary opportunity to form a nation-wide network of health promoters and to work closely as a good supportive team to initiate many programs, projects and movements for the development of population health. I have worked in health promotion for ten years now. I believe that working in our field requires a good training, which I was lucky to obtain during my master degree in health promotion at Bergen University. I have always been interested in community processes, and now I have the opportunity to learn much more about them within my doctoral studies a University of Southern Denmark. It has not been easy to select only five of the most influential resources in health promotion and my selection reflects some of my most satisfying personal experiences of the last ten years.Friends and colleagues (networks) in health promotionThe best resources in health promotion are undoubtedly my good friends and colleagues. Their part in my professional life (also in my personal life) has been most valuable. I was a convinced and deeply committed clinical psychiatrist, before I met some special people, who were convinced and deeply committed health promoters. And look at what they have done! I have distanced from psychiatry quite a lot (but not completely!) and I have drowned into health promotion hopelessly!The number of health promoters and networks of health promoters is not very big, and if one has worked in this system for several years, one gets to know a lot of people locally, nationally and internationally. Health promotion is networking, especially through IUHPE (2004). There is nothing more blessing as to meet your good friends and colleagues, in whatever corner of the world you arrive, to encounter once more people who speak the same (health promotion) language and who understand what you say. You can listen to them, dispute their views, argue with them, convince them and you are sure that you will always learn something from them. It is not a rare case to decide to attend some conference or meeting just because there is somebody from whom you expect to learn something new and whom you wish to meet. Both your friends and your colleagues within local, national and worldwide health promotion networks are tremendously enriching and emotionally warming. Salutogenesis - a surprise to the medical doctorI have always been a person belonging to 'health care system'. I thought my mission was the health of the people. After working more than ten years as a physician, I suddenly came across the term the term 'salutogenesis', and I truly wondered how was it possible to become a physician without knowing very much about health, except of course, by knowing a lot about pathogenic processes. I tried to find something more about salutogenesis and there it was - in a book by Antonovsky "Unraveling the Mystery of Health" (1987). Antonovsky criticized the pathogenic-curative approach and juxtaposed it against a salutogenic orientation. He did this by arguing that the question, why do people stay healthy? should have priority over the question of the causes of disease and their risk factors. This reversal of priority is exactly what is influential to clinically oriented people. Antonovsky's understanding of health explains that health is not a normal, passive state of balance; rather that health must constantly be re-established. Later, being deeply involved in the health promotion world, I often used the "salutogenetic approach" when I talked with medical people - and I also learned to use the term "health capital" while talking with those from economics and politics.The Bowling Alone phenomenonRobert Putnam's Bowling Alone (2000) phenomenon struck me. He developed one of the most influential hypotheses in contemporary social epidemiology, namely that the primary explanation for health inequalities in wealthy countries lies in the low level of social cohesion. He demonstrated that the simple act of joining and being regularly involved in organized groups has a very significant impact on individual health and well-being. Working so that people may join groups - whether they are organized around enthusiasm and interests, social activity, or economic and political aims - can make a considerable contribution in itself. Encouraging the development of community organisations can also make a significant difference to the experience of being in different communities. If we follow Robert Putnam's analysis through, then we can see for example, that crime can be reduced, educational achievement enhanced and better health fostered through the strengthening of social capital. Significantly this entails working across communities - and in particular sustaining the commitment and capacities already present in community organizations and enthusiast groups, and encouraging those on the cusp to be more actively involved. Robert Putnam has done us a great service here, and while aspects of his argument will no doubt be disputed over the coming years, his central message is excellent. Interaction enables people to build communities, to commit themselves to each other, and to knit the social fabric.Community based participatory researchA couple of weeks ago I opened a book, published just lately, in the beginning of 2003. The book begins with the words: "How is it that the most intimate sphere of our knowledge - the knowledge of our own culture, families, lives, and bodies - has been colonized so fully by the portrayal by others: researchers, epidemiologists, medical sociologists, and even health promotion experts? " . Authors of this book, "Community Based Participatory Research for Health", edited by Meredith Minkler and Nina Wallerstein (2003) make us believe in a very simple way in the capacity of any person to create knowledge about his/her own life. This book is an excellent collection of articles about collaborative approach to research that equitably involves all partners in the research process. It gives such a simple definition to participatory research that you stop and wonder. The definition is stated through Hall's (1992, p.4) words: "Participatory research fundamentally is about who has the right to speak, to analyze and to act". Who has the right ? This book is about cross-cultural and power dynamics, trust and dialogue, ethical and practical dilemmas in community based participatory research and it has a rich list of literature highlighted. This is a "must" for researchers, who have interest in community processes and social inequalities in health.Fourth Generation EvaluationAuthors Egon Guba and Yvonna Lincoln (1989) expect readers to find their book dramatically different from the other evaluation books. And somehow it really is. This book represents a remarkable shift in evaluation practice. Evaluation moves from being a scientific process, beyond mere science - " to include the myriad human, political, social, cultural, and contextual elements that are involved " (Guba and Lincoln 1989, p.8 ). The posture of fourth generation evaluation begins with the assumption that realities are not objectively "out there", but are constructed by people who are influenced by the variety of social and cultural factors that lead to shared constructions. This is not commensurate with the positivist view, where there is only the reality of the people who are involved in the intervention and in the specific context. Guba and Lincoln convince us to believe that the constructivist paradigm exists. Stakeholders and evaluators create the evaluation product in an interaction and this product is rather an agenda for negotiation than a set of conclusions. I found this a stimulating and empowering book.ConclusionIt has been challenging to select just five resources from the huge amount of masterpieces in health promotion. This field has developed quickly during the last decades, and we have been fortunate to have so many wonderful and creative thinkers around us.
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