Friday, 7 June 2013

Update and what gets on the table

Classified as: reflective journal - updates, discourse, theory

(25 June -  just updated this update! - some more recent info, a few corrections and reference details.)

Where the project is up to: I've been conducting interviews and focus groups, discussing what people are doing to promote equity, environmental sustainability and health, and the barriers or enablers to this work.

So far I've done seven interviews and three focus groups in this round. I'm hoping to do one more focus group and possibly two more individual interviews in the next month or so. I've talked with people in all three PCPs.

I'm still transcribing tapes at present so won't discuss emerging themes yet. However I'd like to share some of the thoughts I had about stage one of the research.

The key results of stage one are described on 'The project' tab. This was the stage where ISEPICH participants developed a draft framework - principles for how we should promote equity and sustainability together. ISEPICH research participants then discussed these in more detail in groups.

Some thoughts on this: what discourses does health promotion sit in? What does it contribute to discourse?

There's a lot of complicated definitions of discourse (eg see Wikipedia, but I think of it as the world of ideas and meaning that we live in.

Within this world, there's many discourses. Discourse, as Wikipedia suggests, is like conversation, except it's more than just conversation. It also shapes what you can and can't say - what "gets on the table" as one of the research participants said recently. (What didn't seem to get on the table in this case was a serious discussion about community gardens - more on that in later posts.)

In health promotion, we aim to promote health and wellbeing - it's an idealist aim, devoted to "human flourishing" as Guba and Lincoln say. (Some say utopian, but I think calling it utopian actually reflects our problems with discourse). Often, however, we try to justify it in rationalist and utilitarian terms, including monetary terms. The question is, how relevant is this to health promotion?

Much of what we are advocating is never going to make money for anyone. More walkable cities and more people walking: where's the money in that? Ok, individuals might save money (which is good in a society where we are all dependant on money, especially for poorer people), and some local shops might benefit, but basically there's not much profit in it. This is different from the medical world of fee-for-service and medication, which fits well with a capitalist economy.

We also talk about how much money we save governments by preventing disease, but as this can only ever be theoretical, it's not clear how useful or convincing it is. It also may not work in practice - rather than money being saved, it might actually go towards new programs or better treatments. I'm not sure that we would ever see the health budget cut as a result of our efforts, because in political terms it's pretty hard to cut health budgets. We might say we're preventing the budget from growing by slowing the increase in chronic disease, but again that's theoretical.

The previous reference to capitalism might seem as if I'm doing a Marxist analysis, but actually that's only part of the analysis. Marxist analysis is useful, but ultimately both Marxist and neoliberal approaches are limited. In particular that they both share the assumption that competition and exchange have primacy over care and nurture.

I'm planning to write an article about this so won't go on here, but I'm wondering what people think. When we try to justify our work in terms of diseases prevented or money saved, are we just trying to operate in someone else's discourse? Are we doing ourselves and health promotion a disservice? Should we be challenging the primacy of this discourse rather than trying to fit ourselves in it?

Interested in your thoughts.

Reference cited: Guba, E. and Y. e. Lincoln (2005). Paradigmatic Controversies, Contradictions and Emerging Confluences. The Sage Handbook of Qualitative Research. University of Illinois,
Urbana-Champaign, Texas A&M University, Sage.