However, just as health is not a state that can be measured with precision, nor are health needs straightforward. In assessing such needs, the midwife will also need to consider other issues beyond those identified by Bradshaw. Scope of practice and the boundaries of the midwife’s position, together with the degree of autonomy, will all play a part, along with some degree of dependency on the midwife’s line manager, e.g. the setting up of a breastfeeding workshop or a teenage mothers’ parenting group may be considered by the line manager as a health promotion activity for a midwife, but becoming involved in educational work around sexual health within local schools may, sadly, not be. Another consideration must look at whether the need being assessed is reactive – responding to an expressed need – or proactive – where the midwife initiates the need. Pressures from strong vocal groups of women may introduce bias in how needs are agreed and generate pressure to react, perhaps to the detriment of other women. Acting proactively may mean saying no to an expressed need and initiating a professional’s normative need (Ewles and Simnett 2003). The issue of whose needs come first – the user or the provider – must also be borne in mind when a midwife sets out to develop a health promotion project because this may give rise to conflict between the two, e.g. a user might request a Saturday breastfeeding workshop because child care, parking and attendance are easier to achieve than on a weekday, but the provider may not be able to facilitate this need because of difficulties with staffing, which is usually at lower levels at a weekend. Further consideration about who decides that there is a need and what the grounds are for taking this decision must also be identified as part of the health needs assessment process (Ewles and Simnett 2003).
THE AIMS OF HEALTH PROMOTION
Once a health needs assessment has been completed and a need identified, the next stage of planning is the identification of what is going to be achieved by a health promotion project. A whole plethora of words has been used to describe what is to be achieved – aims, goals, mission statement, purpose, targets, objectives and outcomes, to name but a few. But whatever they are called, it is vital to stress their importance because they indicate what the project expects to achieve. They are important because they allow evaluation to take place, an evaluation that will measure either success or failure. It is therefore crucial that the aims are simple, attainable and crystal clear, as this will allow the evaluation of what has occurred against what the health promoter wanted to occur, and from this the project will hopefully be judged a success.
Aims usually revolve around the themes of process and product. The ‘process’
of health promotion involves the way in which people gain information and understanding, and how their decision-making skills are enhanced in using or disregarding the information as they see fit. The ‘process’ of health promotion, even when aims are specific, is notoriously tricky to measure. The ‘product’ of health promotion, or the end result, is often not quantifiable and is therefore difficult to measure, without involving significantly large numbers of people, and the multitude of other factors that could lead to such a result may not be taken into account (Crafter 1997) (see Chapter 5).
Teenage pregnancy is a good example to use when formulating the aims of a health promotion activity. In terms of process, a midwife may decide that the goals are to raise awareness of sexual issues among first-time teenage mothers, and provide
22 Health promotion and the midwife
a forum where relationships, personal values and contraceptive methods can be openly discussed and explored. The product aim after such an activity may be to increase the length of time between the first and second baby.
The aims of a health promotion activity or project should reflect the needs of the users, not those of the midwife. In raising awareness of sexual issues with teenagers, some of them may choose to plan their pregnancies in seemingly dire social circumstances, although it could be argued that this is about poor educational opportunity and socioeconomic factors, rather than true choice (Teenage Pregnancy Unit (TPU) 2003). It may be difficult for the midwife to accept individuals’ decisions about their lives, but this does not allow the midwife to decide what is best
for these young women. The teenage mothers themselves should also define the issues because they know best the pressures, problems and realities in their lives, and they hold the key to how these areas can be addressed best (Social Exclusion Unit (SEU) 1999, Health Development Agency 2004).
The midwife would have the knowledge to realize that just one-to-one or one-to-small group activities will have relatively little impact on the deep-seated reasons of why first-time teenage mothers fall pregnant quickly with a second child.
Many of the issues in this example are best dealt with at a community level rather than with individuals, addressing the issues of education and socioeconomic problems that affect first-time teenage mothers (SEU 1999, TPU 2003). Therefore, the midwife’s health promotion activity will incorporate working with other agencies (partners), e.g. Sure Start. The Sure-Start and Sure-Start Plus programmes, in which many midwives across the UK are now involved, are excellent illustrations of how the above example can work in practice through work with individuals and in partnership with other agencies. Sure Start has given users an equal stake within the project, has midwives as one of the lead practitioners involved and demonstrates the midwives’ capabilities for working in partnership (DoH 1999b, Wiggins et al. 2003).
SUMMARY OF KEY POINTS
■ Health means different things to different people. It incorporates a delicate combination of factors, some individual and some societal. Adequate definitions of health should incorporate cultural and environmental overtones. If pregnancy and childbirth are not seen as a normal, cultural and/or family-centred event, this has negative implications for the role and responsibilities of the midwife as a health promoter.
■ Health is one of our most valuable personal assets. It can be improved for many women, particularly the increasing numbers who are deemed to be socially excluded.
■ Health and health promotion are moving away from the preventive/medical model to a more holistic one, in which assessment of health factors and coping strategies rather than assessment of illness and risk factors is preferred.
■ Salutogenesis can provide the necessary holistic approach to health promotion that midwives need to provide them with the knowledge and skills to work in their usual health promoting roles, as well as developing their role in public health and partner- ship working.
■ Health promotion is so much more than just educating people and communities about health. It would be a huge misconception to limit the term to just ‘spreading
References 23
REFERENCES
Acheson D (1998) Independent Inquiry in to Inequalities in Health. London: The Stationery Office.
Allen RE (ed.) (1993) Oxford Concise Dictionary of Current English, 8th edn. Oxford: Oxford University Press.
Antonovsky A (1993) The structure and properties of the sense of coherence scale. Social Science and Medicine36: 725–33.
Bradshaw J (1972) The concept of social need. New Society19: 640–3.
Cowley S (ed.) (2002) Public Health in Policy and Practice: A sourcebook for health visitors and community nurses. London: Baillière Tindall.
Cowley S, Billing J (1999) Resources revisited: Salutogenesis from a lay perspective. Journal of Advanced Nursing29: 994–1004.
Crafter H (ed.) (1997) Health promotion and the midwife. In: Health Promotion in Midwifery Principles and Practice.London: Arnold.
Dahlgren G, Whitehead M (1991) Policies and Strategies to Promote Social Equity in Health.
Stockholm: Institute for Future Studies.
Davey B, Gray A, Seale C (2001) Health And Disease – A reader, 3rd edn. Buckingham: Open University Press.
Department of Health (1999a) Patient and Public Involvement in the New NHS.London: DoH.
Department of Health (1999b) Sure Start.London: DoH.
Department of Health (2001) The National Strategy for Sexual Health and HIV. London: DoH.
Dufty J (2005) ‘They have only themselves to blame ...’ Understanding the political, psychosocial and environmental drivers that power the trend for unhealthy lifestyle behaviours in deprived communities. MIDIRS Midwifery Digest15: 115–20.
Ewles L, Simnett I (2003) Promoting Health: A practical guide, 5th edn. London: Baillière Tindall.
French S (1993) Disability, impairment or something in between? In: Swain J, Finkelstein V, French S, Oliver M (eds), Disabling Barriers – Enabling Environments. London: Sage.
Graham H (2000) Understanding Health Inequalities.Buckingham: Open University Press.
Hancock B (2000) Are nursing theories holistic? Nursing Standard14: 37–41.
Health Development Agency (2004) Teenage Pregnancy: An overview of the research evidence.
London: HDA.
Kemshall H, Littlechild R (2000) User Involvement and Participation in Social Care. London:
Jessica Kingsley.
Milburn M (1996) The importance of lay theorizing for health promotion research and practice.Health Promotion International11: 41–6.
the word’ about healthier lifestyles. Health promotion involves rallying societal, governmental and, indeed, global responsibility for the health of individuals and communities. For this to occur, the term ‘health promotion’ must be considered as an umbrella term, which integrates other activities that facilitate the promotion of health.
■ Health promotion must acknowledge the complicated interrelationships between socioeconomic and environmental factors, and health. Individual behaviour is not the only cause of ill-health, and therefore the general health of society will not be greatly improved by health promotion specifically targeted at individuals.
■ The focus for improving public health must be on a social policy that is sensitive to the needs and circumstances of all groups in society, not just the most vocal. To be effective, midwives must work with women as equal stakeholders.
24 Health promotion and the midwife
Royal College of Midwives (2002) What is Salutogenesis?London: RCM.
Social Exclusion Unit (1999) Teenage Pregnancy: A Report by the Social Exclusion Unit.
London: The Stationery Office.
Teenage Pregnancy Unit (2003) Sure Start Plus Pilot Programme – National Evaluation of Sure Start Plus.London: Teenage Pregnancy Unit.
Townsend P, Davidson N (1988) The Black Report.In: Townsend P, Davidson N, Whitehead M (eds)In equalities in Health: The Black Report and the health divide. Harmondsworth:
Penguin, pp. 29–213.
Tudor-Hart J (1971) The inverse care law. Lanceti: 405.
Wiggins M, Austerberry H, Rosato M, Sawtell M, Oliver S (2003) Sure Start Plus National Evaluation Service Delivery Study: Interim Findings. London: University of London.
World Health Organization (1946) Constitution. New York: WHO.
World Health Organization (1984) Health Promotion: A WHO discussion document on the Concepts and Principles. (Reprinted in: Journal of the Institute of Health Education(1985)23 (1): 11–14.)
World Health Organization (1999) Health 21 – Health for All in the 21st Century. Copenhagen:
WHO Regional Office for Europe.