Thursday, 30 March 2017

Reflections on 'Health promotion discourse' and 'mainstream discourse'

Classified as: reflections, theory and evidence, discourse

Yet are not all modern societies hierarchical? Undoubtedly so, but good evidence suggests that the social gradient can vary in steepness, and its impact on health can be ameliorated, at least in part.
(Martin Tobias 'Social rank: a risk factor whose time has come?' Lancet 25 March 2017 pp1172-1174)
In this article, Tobias refers to evidence showing that social rank (in the study he cites this is an occupational ranking classified as professional, intermediate and unskilled) has an impact on health similar to, or greater than, many of the more commonly discussed 'lifestyle factors'. In addition there is a link between "social rank' and lifestyle factors with low social rank increasing the likelihood of risky lifestyles.

Tobias goes on to say: 
Moreover, upstream interventions (eg, earned income tax credits, universal early childhood education) are likely to be pro-equity, whereas more downstream interventions (eg, smoking cessation assistance, dietary advice) typically favour the privileged (who generally find it easier to access material and social support for behaviour change). 

He present a list of "evidence based strategies", which includes "strengthen local communities" as well as improved regulation, tax and transfer, invest in early life, and many others.

The article is open access and can be seen here 

While I support many of the measures Tobias recommends, what I wish to discuss today is the assumption in the first statement quoted that hierarchy is normal, at least in "modern societies" and that what we in public health should be doing is trying to ameliorate it.

This relates to the question of discourse, and what I am calling the 'health promotion discourse' and the 'mainstream discourse' in this study. My analysis in the first stage of this study suggested that there was a shared 'health promotion discourse' amongst research participants, but that at the same time this discourse existed in the context of an assumed 'mainstream discourse'. Some of the key assumptions or values of the health promotion discourse was that it focused on local communities, it aspired to be inclusive, saw people as having a shared responsibility to care for each other, and supported measures to ensure that disadvantaged or marginalised people had a voice and were included. These values were asserted in opposition to an imagined mainstream discourse that accepted hierarchy and inequality as normal, that saw people as entitled to individual ownership of wealth, and that was top down or centrist in its governance approach.

What was not clear in the research, and is still not clear, is how those operating in the health promotion discourse understood equity. They questioned hierarchy and notions of individual entitlement to wealth, resources and unequal power, but it was not clear whether they wanted a society in which everyone was equal and power and resources were shared on that basis, or whether, like Tobias above, they accepted that hierarchy and inequality were normal features of 'modern societies' and that their aspiration should be to ameliorate this rather than fundamentally change it. In fact this is one of the big questions my thesis will pose.

In the reflective stage of the research, one of the ISEPICH community members contacted me after the workshop to question the way I was presenting these discourses. An excerpt from the participant's comments is below:

"I, like you, think there is a world of difference between two discourses that you have identified in the work you have shown us (that of community development, collectivism etc and the world of the individualist/competitive spirit). They seem like 2 parallel universes. I don't see that they are necessarily in total opposition to each other and i wonder, if in the end your PhD work will be able to contribute any practical effect in both these universes,  if it constructs them in opposition to each other. The PhD needs to include some work on how people in these 2 universes might talk to each other. Indeed, i wonder how it would help in the development of your thesis if you perhaps attempted to enter into dialogue yourself with one or more people from a very different point of view (from the IPA?). What might you learn for your thesis from them?"

In practical terms I responded that I wasn't able to do direct research with organisations like the IPA within the constraints of this thesis, though I certainly read their published material as part of my background research. However the participant's broader suggestion that I was constructing these discourses as being "in opposition to each other" is what I want to discuss here. I think it suggests a kind of equality, two-sides-to every-question type approach.

At one level I can see this - if you think about the discourses very broadly as discourses of cooperation and competition. then you can see them as trends that exist within humans and that need to be reconciled. However this isn't the main point for this study. What I am talking about here are orthodox and heterodox disourses (or mainstream and alternative, hegomonic and subaltern, etc discourses).  In Bourdieu's* terms, the orthodox discourse strives to make itself the 'doxa', that which is taken-for-granted, or 'the universe of the undiscussed'. This is what appears to have happened - many health promoters or public health figures, like Tobias, recognise that inequality and hierarchy causes problems for health and wellbeing, but seem to assume that they can only be ameliorated, rather than replaced with something else (such as egalitarian societies).

So it is not a question of looking at the features of both discourses and trying to have a debate between them, but rather of challenging the primacy of the mainstream discourse, and suggesting that hierarchy and inequality are not inevitable features of human society and that alternative ways of understanding the world are possible. 

In the thesis, I attempt to do this in two main ways: one is by looking at the work of feminist and ecofeminist historians who have studied both the rise of patriarchal, hierarchical societies from about 5000 years ago, and the relatively egalitarian societies they replaced; the other is looking at more recent evidence from Indigenous societies, particularly in Australia, that may have been patriarchal in some ways (this is a strongly debated topic^) but were certainly more egalitarian in the way they shared resources. The suggestion in the thesis is that as well as being more egalitarian, these societies were more sustainable in their relationships with land and ecosystem, and that we can learn from them.

 * Pierre Bourdieu Outline of a theory of practice Cambridge University Press, 1977

^ I found a useful discussion of this topic in: Karen Whitney 'Dually disadvantaged: the impact of Anglo-European law on indigenous Australian women' James Cook University Law Review 4:13-38 

Tuesday, 28 March 2017

Results of feedback sessions

Classified as: reflections, project update

This is a work in progress in which I'm trying to summarise what came out of stage 3, the final reflective stage of the project. I have been working in 'real time' on this and updating it as I work, so it has changed several times over the last two days. It is now almost 5pm on 29 March and I think I have the main points down, although I may change it again over the next few days, as I write this all up for the thesis.

(30 March - just remembered I've missed something - comments from a community member after the workshop about the way I was representing the 'health promotion discourse' and 'mainstream discourse'. Rather than adding it here, I think I will do a new post on this.)

The presentation I gave at the feedback session is shown in the previous post.

Reflecting the experience of people working in the field (validation)

In relation to whether the findings as summarised in the presentation reflected people's experience, particularly in regard to factors that helped or challenged their work (these are summarised under topic headings in the table in slide 9 in the previous post):
- there was no negative feedback
- there was one question - participant surprised by limited number of projects concerned with early life, young people
- there were several comments of agreement from ISEPICH sessions and all three feedback sheets received from Wimmera PCP agreed with the statement "the findings from stage 2 reflect my experience well".

Details and examples of comments below.

Examples of ISEPICH feedback (from notes by facilitator and me):
"Captures engaging people and building relationships which is key"
"Engagement of hard to reach populations can be difficult
- Time impost of engagement process with developing partnerships"
"Engagement of hard to reach – work with this group, significant challenge – people attend but don’t always come back – reasons why? Commitment, good and bad days, mental illness, depression, lack of confidence? – transport?
- Eg community garden project – estimates has had 50 people involved over three years but only a few regular attenders
- Some programs may conflict with Centrelink participation requirements for people on NewStart or DSP"

"From perspective of community member, narrow definition of health appears to be a major problem– need to focus on keeping people out of the health system"

Examples of comments from Wimmera feedback sheets (written by participants):

"The findings ... are consistent with my experiences in of working to promote equity within the community. I have found that all of the key topics influence the success of a health promotion activity/ project. I find topic 2 and 3 particularly relevant, as engaging the ‘hard to reach consumers’ has been a challenge within our community ..."

"Health promotion activities are run from the [community] garden with the view that we may engage with those ‘hard to reach’ people as they walk past the garden. It also provides the opportunity to promote the garden and encourage people to take fresh produce to use at home.

Interestingly, the concept that the garden belongs to everyone has had to be often promoted as people seem reluctant to take produce."

A Wimmera PCP participant also commented (feedback sheet):

"To implement engaging health promotion activities we need to have a more thorough understanding of the communities we are trying to work with. This could perhaps be done through further community consultation or partnering with members of the populations/ communities in which we are trying to engage." (This comment was actually made in relation to implications of the research, but it is relevant to how well the findings reflect participants' experience and relates to the local knowledge aspect of Topic 1, and to Topic 2)

In SGGPCP, there were relatively few comments from health promotion network members and they were largely about implications rather than whether the findings reflected their experiences. However one participant who had a long term involvement in the PCP's work talked about issues around addressing climate change, which are related to Topic 3 ('that's a point of view' - ideas values and communication), particularly to meanings of health and the 'core business' of health and community services. This is discussed further under implications, below. During this discussion I also asked why SGGPCP had been able to continue its focus on climate change issues when so many other PCPs had not, and this incidentally supports some of the topic areas. Suggested reasons were (from my notes):
  1. leadership within the PCP particularly from two Executive Officers who were both from a 'non-health background' (tends to confirm topic areas 1 and 3)
  2. connections made in the early days of this work, eg through the Victorian Centre for Climate Change Adaptation and other expert groups and individuals (tends to confirm the partnerships and networks aspects of topic 2, plus the knowledge and expertise area of topic 1)
  3. and possibly because SGGPCP is a bit 'away from the centre' and thus could quietly go on doing this work? (which doesn't exactly fit under any of the topic areas, but supports the general view expressed by several participants in this research that people working at local level are capable of addressing multiple issues in a complex and holistic way if they are not subjected to narrow or 'siloed' direction from 'above'). 
Overall, topic 2 ('walk in their shoes' - engaging people and building relationships), was strongly validated. Topic 3 ('that's a point of view' - ideas, values and communication) was also validated, and the comments suggest the two are seen as closely linked. 

There was less direct comment on Topic 1 ('what gets to the table' - knowledge, power and influence) in terms of the specific issues of politics and politicisation, or management and organisations, that were discussed in stage 2. It should be noted that there were only two community members at the ISEPICH workshop, and of the seven staff members who participated in the ISEPICH feedback sessions, only three had been involved in the project in stages 1 or 2. Community members in stage 2 had been particularly likely to raise issues to do with power, while ISEPICH participants in general had been likely to raise issues relating to management as a challenge. 

Moreover, issues of politics and politicisation had been particularly relevant to environmental or climate change issues in the discussions in stage 2 in 2013, whereas most people participating in the feedback sessions - across all three PCPs - were not strongly focused on these issues in 2016 (as discussed in the thesis, these issues had become less significant across PCPs in general during this time). 

Although issues of power, politicisation and management as challenges were not commented on as much in the feedback sessions, there was some detailed comment on how health promotion or community development are administered and funded - governance issues which touch on Topics 1, 3 and 4. Some of this does tend to confirm the issues of management and organisations and policy/politics as challenges in topic 1. In particular, participants in ISEPICH raised the following issues:
  • example of focus in a council on restricting services, related to rate capping, but also suggested to be continuation of an existing trend
  • also meant anything perceived as duplication or overlapping was at risk, which can include partnering - for example Community Development and Environmental Sustainability discouraged from working together on projects
  • directions from senior management seen as restricting 'community development', council's key focus now depicted as providing services.  
  • new focus on individual service delivery models in federal policy such as My Aged Care and the National Disability Insurance Scheme (NDIS) probably accentuates this, meaning work on social inclusion is likely to miss out
  • some examples -  'High Rise Support Program' in local public housing estates cut back. Cuts to Emergency Relief and similar programs have also meant agencies have had to change their approach, again towards individualised approaches rather than community development or social inclusion
  • possibly also a trend towards selling off community assets 
This participant also noted that the state Health and Wellbeing Plan mentions a 'systems approach' but commented that really there is nothing near integrated systems planning at present

Other participants from ISEPICH also commented on policy and governance issues (these comments were made in relation to 'implications' but are relevant here)

  • there is a “myth” [particularly in government policy] that everyone can get (paid) work
  • some people will not be able to
  • “innovation” is a key word in funding submissions – always have to do something new – whereas keeping existing programs going may be more relevant
  • “social enterprise” can be a positive – eg selling plants from garden to raise funds – but where to draw line? (eg could sell off the whole garden space if it was just a question of raising money) 
Overall, I will note in the thesis that issues of engagement are particularly significant to people working in health promotion and community development at local level. However my earlier, more detailed analysis showed that issues of power and politicisation were particularly relevant to work addressing environmental or climate change issues. Moreover, many of the comments on governance here do go to the issues of policy, politics, management and organisations that were raised in stage 2. Therefore I think the findings of stage 2, including the table of helpful factors and challenges, are largely validated, although the order of topics 1 and 2 could possibly be altered (not sure about this, will think further about it).
Some of the discussion around issues of governance also moved into discussing what should be done, and is considered in 'implications', below. 

Comments on implications

This concerns whether people supported or questioned/disagreed with the implications as I had expressed them in the presentation. This moved beyond reporting on what participants had said into discussing what they had not talked about, eg gender and the history of hierarchical patriarchy. It also looked at the way in which environmental sustainability and equity may be related, which I summed up as saying that it seemed logical that a more equitable society where resources are shared more fairly and used more carefully will be more environmentally sustainable than one where people are encouraged to compete for individual wealth and resources (referring to the health promotion discourse and the 'mainstream' discourse, discussed in the report). It also covered what I saw as the strengths and limitations of current frameworks, analysed in light of the findings of this research, and some possible recommendations for strengthening the frameworks.

I asked for comments on the implications section in slightly different ways in the three PCPs as I was refining questions based on the previous sessions. Details will be included in an appendix in the thesis, but a key point is that in the final session, at Wimmera PCP, I tried to incorporate a general statement summing up the implications of the research and asked participants to respond to that.

The general statement was
"Two overall implications from the research so far are:
1. To promote equity, environmental sustainability and health effectively, we will need to work for more inclusive and egalitarian societies
2. And, in order to do that, we need a clearer definition of what we mean by equity, what we are trying to achieve and how we will get there"  

Some of the comments on these statements have been included at the end of this post as they provide a useful summary.

On practical challenges of addressing environmental sustainability, equity and health 

Some comments from the SGGPCP session based on practical experience were particularly relevant:
  • process of people ‘getting’ why climate change is relevant to health is an ongoing one (including because of the staff turnover in health and community services and in networks)
  • have been wary of using climate change language – see PCP expertise as more about the social impacts rather than the science of climate change
  • but PCP members were interested when had a speaker who was more expert talk about CC
  • in latest project talked more about vulnerability in general – later brought it back to CC eg heatwaves
  • agencies seem to be becoming more interested in issue of disaster management, and embedding readiness for disaster 
  • possibly because they think much of the work on other climate change related issues (eg food security, housing sustainability, active transport) has been integrated into their work now 
  • there are risks of taking a ‘downstream’ approach such as looking at disaster scenarios – one way of addressing this is to ask people: what should organisations have been doing one month before the disaster? Five years before the disaster? (this was used in a PCP workshop). This takes them more ‘upstream’. Resulting ideas tend to be around community connection
  • a related issue is how much responsibility should be borne by community or services (including emergency services) - there is a risk of shifting responsibility onto community but genuine commitment to partnerships seems possible
On governance, management and funding

(ISEPICH - notes from workshop)
  • Important aspect from community engagement is ‘safe to fail ‘projects
  • Gain energy from community on smaller projects with minimal investment and then build on them if show to be working
  • Highlights success of working together 
  • Opportunity for people to learn from experience and draw on existing skills

On the issues of fairer societies as more sustainable societies

There was little comment on the issue of gender and caring and competitive hierarchies as a legacy of patriarchy, possibly because I did not specifically ask participants to comment on that, however one ISEPICH participant commented that she liked to see a feminist perspective being used.

SGGPCP participant from health promotion network (from my notes) - Liked the statement about continually wanting more makes us less sustainable.
Wimmera PCP feedback
All three participants who submitted feedback sheets tended to agree with the statement:
1. To promote equity, environmental sustainability and health effectively, we will need to work for more inclusive and egalitarian societies

Example of comment:

"Yes I certainly agree with this, both in terms of our local community and at the broader national/global level. As HP workers we really do need to work together and focus our efforts on supporting/facilitating community initiatives. We also need to recognise and celebrate the great projects/activities that are happening in our rural communities .... . Perhaps less optimistic at the national/global level – growing inequality worldwide, current political environment, increasing pressure on finite resources, globalisation of labour markets/workforce, preoccupation with measuring our national “wealth” in purely monetary terms etc."

Two of the three participants also tended to agree with the statement
2. And, in order to do that, we need a clearer definition of what we mean by equity, what we are trying to achieve and how we will get there

 Examples of comments:

"It is possible that the definition of equity is not well understood, even by health promotion professionals. If the definition was broken down more clearly, then health promotion activities could ensure they were aiming to achieve equity and provide inclusive and accessible interventions."

"During the planning phase of our IHP 2013-17 Plan we met with our partner agencies to articulate our shared vision -“to work with our communities, particularly with the most disadvantaged, to maximise their health and wellbeing, reduce the prevalence of risk factors and increase the prevalence of protective factors”. Through a series of forums we discussed the social determinants of health, the “definition” of equity, the sub groups in our local population who experience greater disadvantage and agreed that our future hp work would have an equity lens overlay. I think we have a reasonably clear definition of equity now – it’s really how to apply it in practice in local communities. The disadvantaged in our Wimmera communities tend to be the “hard to reach” groups. As a PCP strong partnerships, identifying/championing community leaders and a settings based approach have been really integral to successful outcomes. eg. Horsham North Primary School Garden project – low SEIFA area/high Indigenous school population. School setting, broad range of partners (including local Council), shared vision/action plan, and committed volunteers/& school community."

In relation to this comment, however, I refer to the concerns about the 'national/global level' previously mentioned. This disjunction between what is happening at local level, including what health promoters are doing, and what is happening in the broader society (and what health promoters are or could be doing about it) is a key issue that I will discuss further in the thesis. For example, one could ask: are health promoters at the local level addressing issues of equity and the social determinants of inequality and environmental degradation and climate change? Or is their work at local level more a 'downstream' response to determinants operating at the national and global level that health promoters are not fully engaging with?

One of the three participants was not sure whether they agreed with the second statement above, but didn't explain why, which possibly tends to reinforce that the issues around equity are complex!

Finally one of the Wimmera participants commented:

"Really enjoyed reading the summary report – found it stimulating and thought provoking. Some really constructive suggestions for progressing our work.

Many of the questions posed are really fundamental societal ones. Ultimately what future do we want for our world?"

I think is a very fitting question to conclude this post. 

My sincere thanks to all who participated in this stage of the project and in all the earlier stages.