HEALTH PROMOTION: A SUITABLE MODEL FOR HEALTH CREATION? A limited analysis

A traditional professional model of health promotion is available. However, we are not advocating that social work should adopt this, because of the dangers it embodies of compounding health inequalities. As the preceding two examples imply, health promotion messages have frequently targeted individual behaviour and given precedence to professional over lay understandings, without giving appropriate weight to the inequitable material and environmental circumstances and social forces in which lay efforts are enmeshed (DoH 1992). A focus on lifestyles and education remains persistently apparent in aspects of current government policies, despite its rhetoric (DoH 1998a). The programme of action to improve the health of children in the care system outlined in Quality Protects (DoH 1998d) targets measures for surveillance, immunisation and informationgiving which will be of only limited benefit in the absence of action to improve the material and emotional circumstances and prospects of children in care and afterwards (Bywaters 1996).

The development of Healthy Living Centres also shows evidence of a combination of welcome attention to promoting health amongst disadvantaged communities (such as older people, minority ethnic groups and those living in poverty), but with a continuing focus on individual behaviours (DoH 1998e). This limitation in analysis feeds into health promotion policies and practices which can exacerbate inequalities in the chances of securing health. First, focusing excessively on individual behaviour can deflect attention from the more profound effects of wider social, economic and environmental circumstances. As described in Article 2, the material conditions of lay health work became more unequal in the UK during the 1980s and 1990s, with damaging consequences for many of the basic essentials of good health – income, housing, warmth, clean water, food, social support, and freedom from environmental hazards (Drakeford 1997; Ruane 1997; Standing 1997). The impact of business was also obscured, with the reluctance of the last government to impose ‘unnecessary regulations’ (DoH 1992: 106) on tobacco, alcohol and other industries finding echoes in the Labour Government’s resistance to an early ban on tobacco sponsorship of Grand Prix motor races. A second way in which health promotion and prevention can unwittingly exacerbate differences in health chances is if interventions, such as immunisation uptake (Reading et al. 1994) or health checks provided by GPs (Gillam 1992), are not equally accessed, or if they produce greater gains for those who are relatively better off (Blaxter 1990; Nettleton and Bunton 1995).

Third, health promotion and prevention approaches can incorporate institutionalised discrimination. The previous government’s response to the emerging AIDS epidemic in the mid 1980s exemplifies this point. Homophobic and pro-family attitudes prevalent in the Tory party at the time reduced the effectiveness of both the public information campaign and the response of mainstream agencies (Watney 1996). Information was not effectively targeted at the gay community where the risk was greatest, while Section 28 of the Local Government Act blocked discussion of same-sex relationships in schools (and local authority residential homes) (King 1993). Ahmad (1993) and Douglas (1996) have drawn attention to racist thinking underlying health promotion activities resulting in cultural pathologising, stereotyping and victim-blaming. For example, commentators have pointed out the absence from sex education materials provided by both public authorities and voluntary sector agencies of ethnic minority images and culturally appropriate content (Baxter 1994; Sanga, personal communication). For many women on low incomes the legacy of individually focused health promotion material, urging, for example, healthy eating and active leisure pursuits, is responsibility without the power to exercise it.

Oakley’s rule (1989), discussed above, carries the implicit rider that the damage which can be caused by lay health promotion falls unfairly on women because, in most households, women hold primary responsibility for the welfare of male partners, of children and sometimes of other family members (Graham 1993). Moreover, some health education messages have reinforced stereotypical ideas and images. One example was the Department of Health campaign against drink-driving which used, as a warning to drivers who drink, the image of a young disabled man in a wheelchair being fed by his mother.

NEW LABOUR: NEW POLICIES FOR HEALTH CREATION?

‘Our Healthier Nation’ (DoH 1998a) explicitly argued against such ‘victim-blaming’ approaches to health promotion and prevention. It proposed that responsibility for maximising population health is shared across sectors, with roles for central and local government, health authorities, business, voluntary bodies and individuals. It was argued that this ‘involves a range of linked programmes including measures on welfare-to-work, crime, housing and education, as well as health’ (DoH 1998a: 5). The approach was reflected in the subsequent announcement of national priorities’ which emphasised ‘tackling the root causes of ill health … [including] fundamental inequalities in health’ and ‘breaking down barriers between services’ (DoH 1998b: 3).

These twin objectives were repeated themes in the structural changes announced as the programme to modernise the NHS (DoH 1997a) and local government (Department of the Environment, Transport and the Regions (DETR) 1998a). Health Action Zones, based on local partnerships and covering at least the area of a Health Authority, were to ‘achieve progress in addressing the causes of ill health and reducing health inequalities’ (DoH 1997b: 1) ‘linking the contribution of health and social services to work on regeneration, housing and employment’ (DoH 1998b: 20), with about £50 million allocated to the first two ‘waves’ announced (DoH 1998f). Healthy Living Centres, funded through the New Opportunities Fund of the National Lottery, were also to be allocated £300 million ‘to promote health, helping people of all ages to maximise their health and wellbeing, whatever their capacity for “fitness” in the traditional sense’ (DoH 1997c: 1). In each case the requirement of inter-agency partnership was coupled with an expectation that local people would be consulted, given opportunities to participate or be directly involved in project management.

Extended surveillance?

These ‘new’ forms of health promotion which emphasise community involvement and self-determination may seem more appropriate for social work, but contain their own dangers. They may increase inequalities in power, by extending forms of professional surveillance while generating increased opportunities for profit and exploitation (Bunton et al. 1995). Nettleton and Bunton (1995) argue that the concept of empowerment may reflect the appearance rather than the reality of redistribution of power and may hence institutionalise social divisions, producing acquiescence in inequitable, health-threatening conditions (Grace 1991; Wainwright 1996). Moreover, the shift of health policy from treatment to prevention has been characterised as an extension of surveillance (Nettleton and Bunton 1995). The increased focus of attention on risk factors, particularly those which emphasise either behaviour (smoking, diet, physical activity) or the characteristics of a population (being socially excluded), extends the scope for intervention in two senses.

First, it extends the areas of people’s lives which are subject to the ‘gaze’ of health professionals or governments; second, it increases the proportion who are subject to surveillance, from those who are sick to those who might become sick (i.e. the total population). A further consequence of such new public health policies is a shift from intermittent external surveillance by professionals to continuous self-surveillance. All aspects of ‘lifestyle’ come under scrutiny, from exercise to eating, from sex to stress management. A ‘healthy’ regime requires constant self-reflexive scrutiny of activities, intakes and internal reactions in response to myriad health messages.

According to Nettleton and Bunton (1995: 53): ‘From this perspective health promotion can be seen as one of many forms of contemporary governance which, through the establishment of appropriate social identities, forms a crucial dimension of effective social regulation.’ The obligations of the citizen are not only to strive to become well if they fall sick, but to work not to become sick in the first place (Hepworth 1995). The disciplinary force is considerable, especially in a time of constrained public health and social care provision and insecurity of employment. This extension of surveillance is also patterned by social inequalities. As Nettleton (1996) argues, women, as the main recipients of health care and the primary targets of health promotion policies, are particularly subject to surveillance. However, as Hann (1995: 37) points out: ‘Although health advice is orientated towards women, it is the health and health needs of men and children that appear to be the goal of such activities.’ Women also share with other groups – gay and lesbian people (Davies and Neal 1996); Black people (Watters 1996); elderly people (Ginn 1993) and disabled people (Shakespeare 1995) – the position of being seen as vulnerable, dangerous or a drain on resources (Castel 1991). This renders them the targets of health surveillance not necessarily in their interests.

Anew role for social services?

Notwithstanding these concerns, a role in health creation for local authority and voluntary sector social services agencies, through an explicit agenda of tackling social disadvantage, is clearly signalled. As ‘Our Healthier Nation’ puts it: High quality social services play a vital role in the health of the people they serve. Decent support for older people, whether at home or in residential care; the protection and care of vulnerable children and young people; support for people with mental health problems; and helping people with disabilities live more independent lives: health and social care are often one and the same. By protecting the vulnerable, caring for those with problems and supporting people back into independence and dignity, social services have a vital role in fostering better health. (DoH 1998a: 23) However, as we turn now to examine social work’s record on health creation and the potential for the future, we will argue that a substantial change in the awareness, attitudes and actions of social workers and social work agencies is necessary if this potential is to be realised.