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Five useful studies for an epistemological and methodological paradigm shift in Health Promotion

by Robert Bastien, researcher, Direction de la santé publique de Montréal (Montréal Public Health Department) and clinical teaching assistant, Faculty of Social and Preventive Medicine at the University of Montréal

This review is dedicated to Michel Perreault, Monique Besse, and Geneviève Paicheler.

After all, the sanitation and the agriculture of to-day are

still in the rudimentary stage. The science of our time has

attacked but a little department of the field of human disease,

but even so, it spreads its operations very steadily and

persistently..

A Public Health professional since 1988, my vision of intervention and research has been strongly influenced over the past years through the reading of different articles and mostly through the completion of my doctoral research. In this article, I would like to share five books that have significantly triggered an evolution in my perspectives and my practice. For my fieldwork, I spent several months in a high school trying to understand the differing perspectives of teachers, staff and students, as to how health promotion interventions take place in such an organisation. This experience allowed me an appreciation of the importance of acknowledging these differences. As with any ethnographic study, field research is in constant dialogue with related literature. The texts I present here remain a source of perpetual inspiration for me – an inspiration I hope to share with readers of this journal.

Goffman and face to face interactions

If one accepts that preventive knowledge is a ‘locally’ developed social construct, face-to-face interactions between health professionals and so-called target groups provides researchers with a rich and useful prism through which they can better understand the multifaceted rainbow of the natural, real-time production of health promotion discourse.

In this respect, Erving Goffman, in Les Rites d’interaction (1974) provides remarkable guidelines through the development of a veritable sociology of the event and the situation by his detailed and meticulous analysis of conversation rituals. As he points out, face-to-face situations of exchange constitute an object of study in themselves, since they represent the smallest loci from which the construction of social life can be observed. In the area of health promotion, an important part of the dispensing of preventive knowledge is mediated by speech, or even conversation. However, we pay almost no attention to the verbal act because it strikes us as minor and insignificant. We prefer, in the mainstream, the obvious and technical aspects of prevention: the correct use of intervention guides, the appropriate use of images and technology that favour a proper and direct dissemination of preventive knowledge, the mastery of knowledge, etc. A cursory reading of the evaluation reports of health promotion projects will easily lead us to acknowledge the extent to which the modalities of exchange are neglected. However, if we accept Goffman’s work as our inspiration, and view conversational exchanges between health facilitators and their audience as an object of research in itself, it becomes possible to achieve a more incarnate level of necessary knowledge for the development of intervention programs.

Let’s look at the following typical examples: a teacher who raises the topic of suicide prevention with students in class; a street worker who outlines the advantages of reduced-risk drug injection to a drug user; a nurse who offers a young girl pregnancy counselling in a health center.

These examples of situations involving apparently ordinary conversation are marked by different interpretative conflicts that require discursive adjustments and alterations by all participants to help keep the exchange active and alive. And all of these situations involve, to varying degrees and for different reasons, a field of contestation where the players, a term used by Erving Goffman, accept to participate in the play or withdraw from it. The possibility of withdrawing from or continuing to participate in social interactions whose object is prevention is determined in the first place by the context of the exchanges. The theme of the exchanges, that is, the social and health issues that form the interactional framework, recedes more than one would expect into the background of daily situations, whereas we in the field of health promotion often tend to place it in the foreground.

Barrett and Interpretation Conflicts of Sociosanitary Information

The most frequent error we commit in research and in planning health promotion projects on social health risk prevention is that we imagine that our health- and risk-related preoccupations are shared with a relatively equal intensity by the individuals and social milieus we target. The onset of AIDS has doubtless increased, in the West more than elsewhere, the penetrative force of preventive imagery in the universe of collective representations. In this sense, we are probably correct in imagining the existence of a certain convergence between contemporary preventive institutions and a vast ensemble of diverse audiences: homosexuals, drug users, young people, etc. But it appears risky to speak of a symmetrical type of commonality that reflects, in the functionalist sense of the term, a system of unified thought and action free of contestation and interpretative conflicts. In fact, it suffices to spend a bit of time observing, for example, a teacher who raises the question of a healthy diet with students in class to realize to what extent preventive knowledge can quickly spark conflictual situations that require teachers to adjust and transform the knowledge they are presenting. Rather than see these situations as problems or errors, it would be better to use them as the foundation for the development of a pragmatic understanding of health promotion. While the overt subject of Robert Barrett’s study entitled The Psychiatric Team and Social Definition of Schizophrenia (1995) is schizophrenia rather than the field of health promotion, I believe it makes a significant contribution to our field, precisely because it presents interpretative and disciplinary conflicts as propositional forces that generate new categories of knowledge and not as a limitation or force that must be opposed. Barrett seeks to understand, from an ethnographic viewpoint, how the schizophrenic’s identity is created. He bases his theoretical hypotheses on observation, and then seeks in texts explanations to problematic situations. This interaction permits a very strong convergence between micro- and macrosocial aspects and represents, for social research in health promotion, a valuable perspective for interpreting our results and their translation into effective interventions.

Institutional influences on the transmission of Health Promotion messages: Goffman and Coulon.

The educational institution, for example, requires from its constituents, and especially from students, that they conform to the institution’s rules and power, at the risk of being suspended or expelled if they do not conform to them. These rules include, to be present in school and in class, to show respect, to hand in their work, to give the right answers to the right questions, to refrain from violent behaviour, etc. The rules that prevail in an educational institution can differ from those in a prison or on the street, if the latter constitutes a living place. Neglecting to consider the influence of rules and powers related to the context of a social organization while attempting to understand the significance that individuals give to preventive knowledge in the interactions they initiate is like attempting to read a book with our eyes closed.

In the field of microsocial studies, the notion of rule is capital. In a way it constitutes the key for assigning meaning to the behaviours of people within society. From this perspective, the question is not to study how people conform to the rules and powers that rule their behaviour, but rather to analyze, in real time, what people do with the rules, how they adapt and transgress them to obtain advantages and privileges, and above all how they invent other rules to legitimize their actions. To address the study of health promotion as a kind of specific knowledge that develops under the influence of social settings, I suggest two works. The first is by Erving Goffman and is entitled Asylums (1968). This colossal work, the fruit of a participatory observation over several years in an American psychiatric hospital, enables us to grasp the daily life experiences of those living in such an environment. As far as I am aware, this is one of the first times that defiant behaviour and informal manoeuvres enabling one to benefit from the contingent rules of a setting as austere as an asylum are analyzed as specific categories of knowledge. Indeed, Goffman invites us to differentially perceive and understand the reality of the Other. And this, not based on our convictions and certainties but rather by acknowledging the meaning assigned to this reality by considering the context in which he or she evolves.

The second work that I have selected is a treatise that deals with both the theoretical foundations of micro-social research and the approaches, such as direct and participatory observation, that allow this type of study to be carried out. I am referring to Alain Coulon’s book Ethnométhodologie et éducation (1993), which, as its title suggests, is concerned foremost with the organization of social life in school settings.

As several of health promotion projects involve these settings, I recommend the book for a better understanding of the complex universe that a school is, and in particular a classroom; by extension this helps to develop another perspective of the institutional universe where our interventions take place.

Conclusion: the importance of the present time and institutional power

I believe there is a flagrant lack of empirical research dealing with these tiny units of meaning, that is to say, the social interactions that revolve around the dispensation of health knowledge. Why is this the case?

The answer lies partially in the strong influence of positivism in health promotion research under the influence of American social psychology and epidemiology, which has restricted the health promotion field to experts whose knowledge and related research is, according to Michel Foucault, conceptualized and presented as truth-knowledge. Since the founding of modern public health over a hundred years ago, the effects of this knowledge on common sense wisdom and individual behaviours have been evaluated a posteriori. Especially today, a very high percentage of studies are carried out based on a spatial-temporal model (present, past, and future time). Everything that concerns the "present time" and the spaces in which social interactions take place is more or less neglected; worse still, only on very rare occasions do we question the manner in which health promoters interpret, transform, and deal with this knowledge in the context of their practice. Research appears condemned to study - essentially on a prospective basis - a past reality (the dissemination and appropriation of knowledge) in a future time (moment when knowledge is transformed into action).

The first four works that I recommend were all constructed on the basis of direct or participant observation. Jean Copans (1996) has already noted that ethnography represents a science of the present time precisely because it allows us to grasp in ‘real time’ the way in which individuals interact.

In the field of health research, we refer to texts for two main reasons: to reaffirm our convictions or to destabilize ourselves with respect to our object. The urgency to act and find solutions to the ills that besiege our population forms the foundation of our practice, and we have little wiggle room to consider other ways of constructing a problem, let alone to suggest solutions that escape the dictates of the accepted predictive models posited, for example, on the rationality of our subjects. Given the important space that these models occupy, and the influence of the social responsibilities that we bear, we tend most often to base our way of conceiving reality on the so-called tried-and-tested models rather than submitting them to epistemological interrogations with the potential to question the foundations of our certitudes.

A large literature deals with this question; above all, philosophy succeeds the best at scrutinizing our way of analyzing, understanding, and giving meaning to reality. Therefore, the final work I suggest deals precisely with our certainties, uncertainties and the power of institutions to shape our reality. The book, by Mary Douglas (1986), is entitled How Institutions Think. Briefly, it proposes a theory of institutions via the intermediary of epistemological issues raised by sociology and anthropology. Positing that prevention can easily be conceptualized as an institution in itself for those who use it as an epistemological niche, this book provides critical interpretive perspectives that allow us to explore the limits and possibilities of the versions of the world that it produces.

* Thanks to Shelly Abdool and Sophie Dupéré for their help in editing the English translation of this paper.

References

1. Barrett, Robert, The Psychiatric Team and Social Definition of Schizophrenia, Cambridge University Press, Cambridge, 1995. WWW
2. Coulon, Alain, Ethnométhodologie et éducation, Éditions Presses Universitaires de France, Paris, 1993. WWW
3. Copans, Jean, Introduction à l'ethnologie et à l'anthropologie, Éditions Nathan Université, collection 128, Paris, 1996 WWW
4. Douglas, Mary, How Institutions Think, Syracuse University Press, Syracuse, 1986. WWW
5. Foucault, Michel, Histoire de la sexualité, vol. 1, La volonté de savoir, Éditions Gallimard, Paris, 1976. WWW
6. Goffman, Erving, Asylums: Essays on the social situation of mental patients and other inmates, New York, 1961. WWW
7. Goffman, Erving, The Presentation of Self in Everyday Life, Harmondsworth, 1972. WWW

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