This is Ewles and Simnett’s only approach that does not directly concern the individual.
Society is seen as central to health in that changes need to be made on social and environmental fronts, making the ‘healthier option’ easier to achieve for most of the population. An example of this societal change within the UK can be seen in the current discussions about banning smoking in public areas. Democratic movement towards such political action is said to make the whole environment more health enhancing.
The approaches offered by Ewles and Simnett are not without their problems. They can be seen as rather idealistic and simple in their layout. They do not necessarily address the issue of values, attitudes and beliefs held by both the health promoter, in this case the midwife, and the woman and her family, which will have a significant impact on their use. The authors themselves have identified that these approaches are not perfect and need to be questioned and challenged ‘as part of a healthy debate on the theory and practice of health promotion’ (Ewles and Simnett 2003, p. 46).
However, the delineation of the approaches is clearly very useful in developing health promotion theory, and helping midwives to understand these approaches as well as clarifying their aims and values when using them.
Reflection – 1
Reflect on your two most recent health promotion activities within your current area of practice, e.g. a one-to-one interaction with a client, a group education programme such as a breastfeeding workshop or a community activity within Sure Start. Try to use different health promotion activities.
Looking at the approaches of Ewles and Simnett identified above pinpoint what approach/approaches you used.
Applying health promotion models and approaches to midwifery care 41
In earlier work by Tannahill (1985), developed further by Downie et al. in 1990, a modern approach to health promotion was identified. This approach addressed issues surrounding positive health, life skills, self-esteem, participation, and dimensions of health, choice and behaviour. The authors identified that:
The modern approach uses a broad information base and sound
educational principles, and recognizes the importance of the sociopolitical factors in health and health related behaviours. It is a participatory model.
Downie et al. (1990, p. 48) Downie et al. (1996) developed this further and endorsed a model of health promotion, which maps out the various possible domains of health promotion.
Three areas were identified:
1. Health education 2. Health prevention 3. Health protection.
These three areas frequently overlap (as shown in Figure 4.1) and within these overlapping circles lie the seven possible domains into which health promotion activities may fall.
Health education
This is defined as ‘all influences that collectively determine knowledge, belief and behaviour related to the promotion, maintenance and restoration of health in
Health protection
1 3 6
4 5
2 7
Prevention Code:
1. Prevention of disease, ill-health or abnormality
Preconception folic acid supplementation
‘Stop smoking’ campaigns Child vaccination programmes Systematic antenatal care Breastfeeding workshops
Employment law for pregnant women Campaigns by charity organizations to improve living and working conditions for pregnant women 2. Health education and prevention
3. Prevention and health protection 4. Community development 5. Health education 6. Health protection
7. Health protection and health education
Example:
Health education
FIGURE 4.1 A model of health promotion. (Reproduced from Downie et al. 1996, with kind permission of Oxford University Press.)
42 Using health promotion models and approaches in midwifery
individuals and communities’ (C Smith 1979; cited in Downie et al. 1996, p. 27).
This includes incidental as well as intentional education, and Downie and his co-authors also acknowledge the two-way communication process of education, where teaching and learning can come from and to both the midwife and the woman.
Health prevention
This encompasses avoiding, or reducing, the risk of different forms of diseases, accidents and other forms of ill-health. It includes contraception, sexual health, and breast and cervical cancer screening. Downie et al. (1996, p. 51) went on to define the four aspects of prevention:
1. Prevention of the onset or first manifestation of a disease process or some other first occurrence through risk reduction.
2. Prevention of the progression of a disease process or other unwanted state through early detection.
3. Prevention of avoidable complications of an irreversible, manifest disease, or some other unwanted state.
4. Prevention of the recurrence of an illness or other unwanted phenomenon.
Health protection
This incorporates the environmental aspects safeguarding health by political, legislative and social control, which uses a number of mechanisms to achieve positive health by attempting to make the environment hazard free, such as regulation, policy and voluntary codes of practice.
In their approach Downie and his co-authors include both individual and community action in health promotion but exclude curative medicine. They acknowledge overlap in all of the three areas of health promotion that they describe, and see community action as the ultimate in health promotion because it broadly incorporates health education, prevention of disease and health protection. This model offers the health promoter many permutations; however, it does not make explicit the principal political or social values in each approach. Nor does it reveal the authors’ preference as to the methods. Perhaps in not doing so the model offers the health promoter a greater autonomy than other models and approaches do, and make it more appealing to midwives who value their professional autonomy.
Ewles and Simnett’s approach and that of Downie et al. are two of the most quoted in health promotion literature, and others commonly quoted use similar ideas. The two differ in that Ewles and Simnett (2003) construct their design from the perspective of the health promoter, whereas the Downie et al. (1996) perspective is that of health promotion outcomes. Nevertheless, the two approaches offer similarities. Ewles and Simnett’s societal change approach and the element of community development in Downie et al.’s model have much in common. Both encourage community-based health care and each includes an educational approach. Downie et al. acknowledge all influences that lead to learning in clients and communities. However, Ewles and Simnett restrict their definition of education to that which allows individuals to exercise self-development by deciding, without undue pressure from outside, what the issues are and how to interpret them (Crafter 1997).
There are wide differences as well as similarities in the two approaches. Downie et al. do not include a medical approach in the curative sense (although they do
Applying health promotion models and approaches to midwifery care 43
acknowledge preventive medicine) and their model is distinct from that of Ewles and Simnett in this respect. The client-centred and behaviour change approaches of Ewles and Simnett find no reflection in Downie et al.’s model, the latter not sug- gesting how the outcomes of education, prevention and protection are reached.
The major criticism of Ewles and Simnett’s approach must be that, in describing from the perspective of the health promoter, it does not attend to possible outcomes of health promotion. Although the main criticism of Downie et al. must be that, in attending to outcomes, or products of health promotion, the process by which success is measured is missing (Crafter 1997).
Taylor (1990) provides a more sociological approach to what she refers to as health education, although on examining the breadth of her perspectives in today’s terms she could be said to be referring to health promotion. Her ideas take the form of a paradigm map as shown in Figure 4.2.
Radical humanism
The perspective of radical humanism is that of self-development, particularly through personal growth, but with outreaching effects for community develop- ment. Removal from social regulation as far as possible is necessary and in some cases health professionals may be seen as social regulators, in that they are required to work strictly to rules and laws. A group of breastfeeding mothers running their own support group could be considered an example of the radical humanist approach.
Radical structuralism
Similar to radical humanism, radical structuralism is about moving towards change in the organization of society, and indeed is more concerned with changing society to remove barriers to health than changing the individual. Radical structuralism may be exemplified by a nationwide campaign to encourage breastfeeding, including legislation to improve maternity leave, an advertising campaign among the public to improve attitudes towards breastfeeding and the provision of widespread facilities for breastfeeding mothers.
Radical humanist
RADICAL CHANGE
SUBJECTIVE OBJECTIVE
Humanist Traditional
functionalist
SOCIAL REGULATION Radical structuralist
FIGURE 4.2 Perspectives of health education. (Reproduced from Taylor 1990, with kind permission of the Health Education Journal.)
44 Using health promotion models and approaches in midwifery
Traditional functionalism
The traditional functionalist may be seen as the professional who possesses the expertise that is passed on to the layperson, who can then progress to healthier behaviours. An example of traditional functionalism is the existence of antenatal classes aimed at promoting breastfeeding.
Humanism
The humanist is concerned with personal autonomy and empowering individuals through life skills development. A network of NHS breastfeeding counsellors illustrates the humanist quarter of the map.
Elements of other approaches can be seen in Taylor’s ideas, e.g. the traditional functionalist perspective reflects elements of Ewles and Simnett’s medical and behaviour change approaches, and radical structuralism has some common ground with Downie et al.’s health protection approach, in that it is concerned with political and societal changes to improve the health of the public. However, overall, the sociological background to Taylor’s paradigm is so different from the more clinical frameworks set by Ewles and Simnett and Downie et al. as to make these three systems impossible to compare (Crafter 1997).
Similar themes run through many of the health promotion models and approaches used currently in practice but each has a different area of emphasis.
Central to contemporary health promotion is whether action should primarily focus on educating individuals and small groups, or on restructuring society to benefit everybody’s health. This unresolved debate is reflected in the various models and approaches. The problem with focusing on individual responsibility in health is that the collective responsibility of health can be lost, leading to the scapegoating of sick or socially excluded individuals such as teenage pregnant women and pregnant women who experience domestic violence, when it would be better to improve health for a greater number of people by addressing change and health inequalities in society (Crafter 1997, Dufty 2005). Creators of models and approaches must aim as far as possible to design very broad frameworks that acknowledge the political dimension of health-care administration, as well as recognize the day-to-day practicalities for health promoters working with individuals in the community.