Thinking Upstream?

I’ve had several reminders this month of the importance of the upstream focus health promotion. We have been working in prisons, considering the usefulness of peer approaches to improve health and other outcomes. Two prisoners’ stories have stayed with me. One was a teacher, clearly in prison for a long time and so had presumably committed a serious crime. At that time, he was suffering from a serious mental illness that had not been diagnosed. He stated, quite simply, that if he had received the health care he needed, he would not be in prison. The other was a young woman who was relishing the educational opportunities she now had in prison; she was loving learning. She clearly had not had these as a youngster in school, which had been a part of her problem – that familiar drift into unemployment, boredom, and the taking up of a drug-filled lifestyle. Both, in my view, had been let down by the services they should have received upstream, and both were now paying for that.

Another example is how, in the mid-1990s, a group of us was doing work in primary schools in Leeds trying to tackle the impending ‘obesity crisis’ by developing healthier eating and exercise for all children. What we noted was the large number of children who were not only already overweight, but who were obese. The purpose of the project, ‘Apples’ was not to tackle obesity management, but due to our observations, we had no choice but to attempt to provide a service for those families already struggling, so ‘Watch it!’ was set up, initiated by Prof. Mary Rudolf. It did a lot of good for many years as an independent organization, but after being taken over by the Primary Care Trust, it folded. Although we published our findings widely and had the ear of policy makers, the warnings of the obesity problem were not heeded. Now, 15 years later obesity has truly become a ‘crisis’.

In the last week, the Academy of Medical Royal Colleges has made a statement to the effect that the obesity crisis in the UK is becoming ’unresolvable’. They called on the government to take urgent action as ‘generation after generation [is] falling victim to obesity-related illnesses and death’. Moreover they say that the government’s anti-obesity efforts, along with those of previous governments, are ‘disappointingly ineffective’. One in four adults in the UK are now obese and in certain ‘hotspots’, it is as much as 30%. Tamworth in Staffordshire and Gateshead in the Northeast for example, according to the National Obesity Observatory are such towns.  The Academy, comprising 220,000 doctors, sets out an ambitious plan, which not surprisingly focuses on such activities such as NHS staff taking opportunities to talk to patients, an expansion of bariatric surgery, and for the NHS to spend £300m over the next three years to remedy the shortage of weight management programmes. It does also call on the government to tax sugary drinks and to restrict fast food outlets located near schools and leisure centres, but it’s not surprising that doctors think of solutions that they can see from where they stand, in medical settings – which is relatively downstream on the proverbial riverbank.

We know that once doctors are involved, a problem has reached crisis status. On the whole, doctors rescue people once they are struggling in the river. The status of doctors might mean that now government will listen – but what a major disaster it is that government did not listen to the warnings given more than a decade ago by health promotion specialists. We know that individuals behave like this too – people often do not take action on their health until they face a scare, by which time damage has occurred. For governments to behave like this though, is negligent.

The latest outburst about the scale of the obesity epidemic comes at a time of other major concerns about the food we eat. The ‘horsemeat scandal’ shows an extraordinarily widespread fraud, exposing how the free market contaminates food. It does appear that the food industry has been hoodwinked itself, but that same food industry has also deliberately set about not being clear about the calories in the food it sells.  Given that calories are given per 100gms, and that people might not have a clue about what 100gms looks like, food labels contain a ‘portion size’. However, that portion size is chosen by the manufacturer and might not bear any relation to what people might eat. As an example, Kellogg’s new breakfast cereal. ‘Krave’ contains 440 calories per 100gm but the portion size is given as 30gm (four tablespoons). People might think therefore that they are eating about 130 calories – yet will their portion really be only four tablespoons? For more on this kind of trickery, read James Erlichman’s latest book.

Meanwhile, a meeting of the American Association for the Advancement of Science this week has declared that the way we count calories is mistaken, and has been for decades. This has led Prof. Richard Wrangham of Harvard University to declare that the public receives ‘erroneous information about the energy value of many foods’. Basically, the system used for so long (the Atwater system) overestimates the content of some protein-rich foods by up to 20% and underestimates the calories of other foods, especially high fibre foods, (such as muesli) by up to 25%. It seems that labeling does not take into account the calories in fibre.  So the science is not easy, which plays into the hands of the food industry.

Also this week, the government appears to have woken up to some of the effects of its austerity measures, including the dramatic rise in the UK of food banks. The media talks of an explosion in food banks, soup kitchens and school breakfast clubs. Again, in the 1990s, some of us working in school health promotion wrote of the need for breakfast clubs and were involved in setting them up. They are clearly needed more than ever now. The recent investigation into food banks comes from research commissioned by a government department,  (Dept. for Environment, Food and rural Affairs). Those using such food aid are likely to be a tip of an iceberg; the Trussell Trust, a provider of 309 foodbanks reckons that more people use them because they face financial crisis caused by benefit stoppages or delays. Given this food insecurity and more people facing lower incomes and therefore seeking out cheap food, it is not surprising that they fill up on calories, that obesity is worse in deprived areas – and that people want cheap food that tantalizes the criminal elements to provide it in the form of horsemeat. Once again, this government has failed to have any sense of upstream thinking and seems oblivious to the effects of its policies on health and wellbeing.

On a more optimistic note, I was also reminded of the value of health promotion and of early warnings by one of our student groups (on the MSc Public Health – Health Promotion) which has had work from a course assignment adopted by Leeds Community Health Care NHS Trust. The Communicating Health module involves students producing a piece of health information, and this group designed a card to be used in ante-natal booklets held by parents-to-be, on the dangers of cords around the house – the sort of cords found commonly on blinds and curtains. The group (Sharon Underwood, Emma Moore, Emmanual Darko, Janet Berry and Lisa Buchanan) produced a very eye catching but simple postcard sized warning, ‘don’t be blind to dangers’. It’s great to see how the course impacts on practice in this way, and the group, all experienced health workers, have shown how by coming together, they have achieved the creativity needed not only to pass the module, but also to make a difference on the ground.

22 deaths have been caused by cords in the UK since 1999, and tragically, one that hit the headlines last November was that of the three-year-old daughter of wealthy tycoon in London. The Royal Society for the Prevention of Accidents has campaigned for manufacturers to stop making looped cords. Sadly again, it often takes an accident to make people perceive hazards– hence ‘don’t be blind to dangers’ could be a useful, upstream, preventive tool.

Erlichman, J. (2013) Addicted to Food: Understanding the Obesity Epidemic.

Sahota, P. Rudolf, M.C.J. Dixey, R. Hill, A.J. Barth, J.H. Bartrop, J. Chaudary, N. APPLES: A School-based intervention to reduce obesity risk factors:- results of focus groups with children. International Journal of Obesity and Related Metabolic Disorders 1998, 22 Supplement 4, p102.

Sahota, P., Rudolf, M.C.J., Dixey, R., Hill, A.J. Barth, J.H.
APPLES: A School-based intervention to reduce obesity risk factors.
International Journal of Obesity and Related Metabolic Disorders  1998, 22 Supplement 3, p.230.

Sahota, P., Rudolf, MCJ.,  Dixey, R.,  Hill,A.,. Barth, J.,  Cade J., 2001  Evaluation of implementation and effect of a primary school-based obesity prevention programme to reduce risk factors for obesity. BMJ 3 November 1027-1029

Sahota, P.,  Rudolf, M.,  Dixey, R.,  Hill,A.,. Barth, J.,  Cade J.,. 2001 Randomised controlled trial of primary school-based intervention to reduce risk factors for obesity BMJ 3 November 1029-1032

Our new students in Zambia

I’ve just returned from Zambia, where my colleague Ivy O’Neil and I started off the seventh cohort in our Masters in Public Health Promotion. We have enrolled another 26 students who, in the two weeks we were there, completed the first module.

This is our tenth year of working in Zambia, and we have now enabled over 100 Zambians, all of whom contribute to public health, to go through our Masters programme which we teach in Lusaka, using Chainama College facilities. The degree awarded is a Masters from Leeds Metropolitan University, and I’ve written about the advantages and disadvantages of doing a Masters ‘at home’ as opposed to travelling to Europe or elsewhere. See http://www.scirp.org/journal/PaperInformation.aspx?paperID=23517

These ten years have seen many changes in Zambia, with the capital expanding every time we visit. The roads around Chainama College and the well-heeled Arcades Shopping Centre (only opened after our first visit in 2003), are now lined with new banks, swanky office buildings and hotels, showing that business is booming. The roads themselves are far busier with newer looking private cars. This was my twentieth spell in Zambia over those ten years, and for the first time, we had one or two students in the classroom using the latest iPads, and able to connect to the Internet within seconds. This will help us to deliver more electronic teaching to supplement the important face-to-face learning. Of course, the Internet is still not fully reliable, whilst there is also a lot of variation in health workers in their knowledge and ability to use IT.  However, Africa really has leap-frogged the technology, and leads the world for example in mobile phone use. This is resulting in other innovations in a continent where electricity supply is not reliable or is simply unavailable. So, one Australian company is about to release in East Africa a mobile phone charger, charged by the sun and portable enough that people can carry it in their pocket (see illuminationsolar.com).  Samsung started its first solar powered Internet school in 2011 in South Africa, putting in roof solar panels that can power all the electronic equipment inside the school. Samsung has also launched an Engineering Academy to train technicians and service experts within Africa.

There is already what the Ghanaian economist George Ayittey has called the ‘Cheetah Generation’, adaptable, innovative African entrepreneurs who are using technology and concepts such as ‘crowdsourcing’ to develop their own solutions to problems in an environment where governments do not seem able to make life better for ordinary people. One example of this type of crowdsourcing – pooling ideas from experienced and knowledgeable people – is the project called Africa Rural Connect, which supports young farmers in Africa. (See http://arc.peacecorpsconnect.org/)

Yes, there are still major problems in Zambia and in the rest of Africa, and our new class spoke of the repeated (and preventable) outbreaks of cholera, whilst the rains brought misery to those living down the many un-tarred roads in Lusaka, meaning inches of mud. I visited Central Lusaka Prison again, where conditions are still dire. There are also issues to face regarding the boom in Africa’s economies and the influx of investment and ‘aid’ from countries like China and Brazil. Are they going to ‘help’ or merely increase the ‘aid mentality’ and allow Africa’s resources to flow out of Africa to places other than Europe and America? Our students also discussed the changed nature of communities, with it being clear that they, as the new middle class, usually lived in homes with security fencing, electrified in some cases, and where they did not know their neighbours.

On my last evening, I watched Bafana Bafana play Cape Verde in the opening match of the Africa Cup, at a Lusaka pub, the Kalahari Club. It wasn’t a great match, but it was great to see a small nation remain unbeaten by South Africa.  

Zambia are the defending champions from the last tournament, the final one to be held in an even year, in 2012. That tournament was held in Gabon, near to the site where Zambia’s best players were all killed when their plane fell into the sea in 1993. 2012 was, therefore, a special victory.  To be honest I think they will have a hard time repeating it, especially against the likes of Ghana or Cote D’Ivoire, or the hosts, South Africa. Zambia’s French coach, Herve Renard agrees that Zambia are not likely to win.

Africa’s Cup of Nations is a reminder of how intertwined Africa is with Europe. Once again, for its football industry, Europe has mined African talent. Just over half the 368 players in the tournament are on leave from their European teams. All but two of Cote D’Ivoire’s 23 squad play in Europe; Didier Drogba is playing in probabaly his last Cup of Nations, but has gone to China -  Shanghai Shendua -  to play out the remainder of his career, but many major other Cote D’Ivoirian stars are playing in England – Yaya Toure, Kolo Toure, Abdul Razik with Man City, for example. This is the reason why the African tournament  has been moved to be in odd years, so as to be in different years to the World and European Cups.

The light hearted nature of a football tournament is a welcome relief from some of the other conflicts which burn away through parts of the sub-continent and which draw in European intervention. While I was in Zambia, French air power arrived in Mali. This is after a long period where Mali’s problems appeared to be ignored, a country seen for a while as a model of democracy. In March 2012 an officer trained in the USA seized power in a coup, whilst in northern Mali, various jihadist groups and ethnic groups including Tuaregs, who were armed by the previous Libyan regime, are making war to force separation from the south.  This week, the main separatist group, the MNLA decide to join the Franco-African forces and so will be fighting its former Islamist allies. The politics and history of this region are extremely complex, and beyond any easy comprehension by outsiders. This point should serve as a warning to American/European powers keen to intervene.

The conflicts in Mali might have made our newspapers because people are vaguely aware of Mali – its music and culture – but there is also conflict occurring in the Central African Republic, and this has not made the western media.  Louisa Lombard, a postdoctoral fellow at the University of California at Berkely has described the CAR as “a laboratory for international peace building initiatives”. She argues that the model promulgated by the UN, of ‘DDR’ – disarmament, demobilization and reintegration - of armed groups to help them return to normal civilian life isn’t working. She suggests that western states try to fix the supposed deficit in an African state’s inability to provide services for its citizens by providing cash and skills. However, her research shows that the fighters against Francois Bozize’s regime (he himself seized power in a coup in the CAR in 2003) did so because they were poor, if they became rebels they would gain from disarmament programmes, and the government had failed to provide basic services such as roads, schools and primary health care.  Her conclusion is not only that DDR doesn’t work, but it makes the situation worse, yet the western powers keep using it. I guess the lesson is that European involvement in Africa is often misguided and is always going to make a complex situation even more complex.

It’s something that my colleagues and I think about a lot. We do believe in what we are doing in Zambia and The Gambia; we hope we are contributing to positive ‘development’ and so helping to bring more health justice to Africa.

Africa still remains as the recipient of western ‘help’ in the popular imagination – on my way home I ran into some fellow passengers on the European leg of my journey. They had been in the USA and when they knew I’d been in Africa, they commented that their granddaughter had been to South Africa “to show them how to grow vegetables”. After hours of snow-caused delays, I didn’t have the energy to explode, or at least to try to put a different view to these proud grandparents. The idea of a young girl who had probably never grown anything in her life going to a foreign land to show seasoned agriculturalists how to grow vegetables was preposterous, and I mused on what her grandfather would say if an African appeared on his allotment to tell him how to improve his onion crop. 

40 years of health promotion at Leeds Met

We have just celebrated forty years of health promotion at Leeds Metropolitan University. We gathered together previous and current students and staff and Emeritus Professor Sylvia Tilford talked about the early development of the course at Leeds Met, whilst Emeritus Professor Jackie Green joined us in a pre-recorded piece, as she was overseas on the day. Professor Jane South talked about her current work on healthy communities and I talked about some of the global dimensions of our work.

I need to qualify the description ‘forty years of health promotion at Leeds Metropolitan University’ though, as when the course started in 1972, we were still Leeds Polytechnic and only became a University in 1992, when all polytechnics in England became universities. (For anyone unfamiliar, we haev two universities in Leeds - Leeds Met and Leeds University). Also, we started as a health education course, as ‘health promotion’, as we all know, didn’t really take off as a term until the mid 1980s. But – our achievements are significant whatever we call them. In 1972, we were one of three higher education institutions in England asked by the government to develop and deliver health education training for health education officers. Keith Tones was responsible for this development; he of course went on to contribute so many papers and books outlining the principles and practice of health promotion, and commented in the early days about the importance of empowerment (Tones 2001).

Shortly after, Sylvia Tilford joined the department, along with John Hubley and Faith Delaney. Sylvia and Keith, along with Yvonne Robinson produced the key textbook ‘Health Education: Effectiveness and Efficiency’ in 1990, one of the first texts aimed at Masters’ level study. It went through a number of revised editions and was later simply referred to, when we were recommending books, as ‘Tones and Tilford - Health Promotion’.

The course in its earlier days concentrated on the Postgraduate Diploma, as this was the qualifying course to become a health promotion officer. The course was closely tied to practice and students were only accepted with several years of work experience. The primary aim was to provide the theoretical underpinnings to professional practice. In the 1980s and 1990s it was not difficult for students to find work. UK students were employed by local authorities and health services, and those many students who came to us from Africa and Asia were employed in a variety of roles within health and social care, community work and education.

By the time I arrived in 1991, after a decade or so of developing health promotion schools and working in Africa, the course had both health promotion and health education in its title. Keith, Sylvia, Faith, John and I taught the course but we were also developing a research profile and John in particular was doing consultancy work overseas. He contributed mainly in the international sphere, and was a master at producing accessible books aimed at practitioners. He wanted to improve the practice of front line workers. For many years we ran a one-year diploma course at undergraduate level for such workers, which attracted students from all over the world. Some later went on to our Masters’ course. His book ‘Communicating Health’ remains a practical and useful book used in the field, and he went on to produce, with June Copeman, the book ‘Practical Health Promotion’. Tragically, he died at the age of 58 just before this book was published. A second edition has just been produced, being brought up to date and joined as an author by James Woodall.

A couple of years after I joined the team, Jackie Green came to work with us, having been a practitioner at Leeds Health Promotion Service. She went on to

produce another useful book with Keith Tones, (Tones and Green) which in its second edition became Green and Tones (2010).

A major development occurred in 1997, when we set up the Centre for Health Promotion Research, and Sylvia Tilford, who up to that point was the head of the team, took a sideways move to head up the Centre, and I was promoted to head the staff team. The creation of a formal research centre enabled us to house the burgeoning research activity taking place. One of the first major contributions was a piece of research which took forward understanding of the processes of intersectoral collaboration, and one of the papers from that study is still used as  seminal piece today (Delaney 1994). Faith moved on in the 1990s.

The course was popular, and went through a series of name changes to reflect developments in the field. We would spend hours debating what to call the course! In the 1990 and early part of the 21^st century, health promotion was being renamed and ‘rebranded’ variously as ‘health improvement’, ‘health development’ and ‘public health’. There was criticism that health promotion had no delivered its intended promises (French and Milner 1993). Several Masters courses in England changed their names at this point but we felt we wanted to keep the term ‘health promotion’. We did however bend to market demands and call the course ‘Public health – Health Promotion’ – clumsy perhaps, but students were demanding that public health appear in the title, as government ideology had swung away from health promotion and towards retrenching health promotion within the broader (and less radical) public health function. The current fortunes of health promotion in England are described in chapter 6 of the book I mention below (Dixey 2012).

Whilst I was head of the team (1997- 2011), we appointed Mima Cattan, who produced a key book on mental health promotion with Sylvia Tilford, and who drew attention to the issue of loneliness in old age through her PhD studies. Mima is now a Professor at Northumbria University. We also appointed John Barron, a practitioner in young people and schools. Sadly John died suddenly at the age of 48 from a congenital heart condition.  He was passionate about the neglected issue of the mental health of young people, supporting a charity called ‘Young Minds’. Mary Green was another appointment at that time, and she was to prove so instrumental in setting up, with me, the delivery of our Masters’ course in Zambia.

We had become aware that it was proving expensive to study in the UK for students from developing countries. Mary already had a partnership with Chainama College in Lusaka and so we set about seeing if we could deliver the course there. This proved possible when we were awarded scholarships from the Commonwealth Scholarships Commission through their new distance learning committee. We therefore developed a separate course, suitable for Zambia, which we delivered by relays of staff from Leeds going out to Zambia for two-week teaching blocks several times a year (Dixey and Green 2009). We saw this as a way to develop a sustainable workforce in Zambia and since it started in 2004, we have educated successive cohorts, with the seventh cohort about to start in January 2013. Later we also took the course to The Gambia, again on the request of our alumni. We have educated three cohorts there, with the second about to graduate. We again had the welcome scholarships from the Commonwealth and also the generous support of the National AIDS Secretariat in The Gambia which meant that we could educate larger groups (e.g. 37 and 32 in the second and third groups). This way of delivering course is a creative solution to the lack of higher education infrastructure in Africa, and is also, through capacity building, contributing to the development of that infrastructure, as well as building up the health promotion workforce (Dixey 2012). During the time the course has been running in The Gambia, health promotion has been more firmly embedded as a separate unit within the Ministry (Dixey and Njai in press).  Mary Green retired three years ago, leaving a wonderful legacy, as our partnership with Chainama College remains strong.

During the late 1990s and into the 2000s, a number of staff joined the team. Joy Walker was with us for a few years, and Jane South, Ruth Cross, Diane Lowcock, Ivy O’Neil, James Woodall all joined and stayed. Sally Foster has been an essential part of the team since before I arrived, but as a sociologist and health promotion graduate, she was located in social sciences; she and Louise Warwick Booth (a social policy and sociology expert) and Chris Spoor (a health economist) only formally joined the health promotion group in the early part of the 2000s.  Two very experienced practitioners also joined us - Judy White from years of practice in health promotion in Bradford, and Skye Hughes from working for NGOS and at Universities in Kenya and Botswana. Skye left in 2012.  James originally did his PhD with us, one of a large number of PhD students in our thriving research student community.

My initial expertise was in development and I had worked in Africa, as had Mary, John Hubley, Sally, Ruth and Skye. We were also joined in this African work by Zac Mwanje, a Zambian based in Leeds. The opportunity to deliver our course in two African countries has been a highlight of my career and it’s something I feel especially proud of. We have all gained hugely from experiencing the warmth of people in these very two different countries, working with colleagues in Zambia and The Gambia and enjoying developing additional collaborations and projects (Foster et al 2012).  We are planning to deliver our Masters’ course in Ghana, which will begin in 2013. 

The Centre for Health Promotion Research went from strength to strength, firstly under Sylvia’s leadership, then under Jackie Green’s once Sylvia semi-retired. Jackie and Jane South wrote a useful book on evaluation (Green and South 2006), and many of the projects the Centre has undertaken have been evaluations of health promotion initiatives. After Jackie left us, the Centre was co-directed by Jane South and Mima Cattan, and once Mima left, has been very ably led by Jane South. She has developed special strengths in community engagement and in people-centred public health, ideas formulated into a recently published book with Judy White and Mark Gamsu,  our visiting professor (South, White and Gamsu 2012). We have contributed a lot to the development of empowerment approaches, through a series of reports commissioned by Altogether Better (see for example, Woodall et al 2010). Gianfranco Giuntoli, Anne-Marie Bagnall and Karina Kinsella work with us in various research roles, delivering the work of the Centre alongside the rest of the team, all of whom also teach. Our output can be seen through these pages: http://www.leedsmet.ac.uk/hss/research_centre_for_health_promotion_research.htm

Louise, Ruth and Diane have made important contributions to the health studies literature (Warwick Booth et al 2012 and Warwick Booth et al forthcoming), and since 1990 when it was established, we have all contributed to the degree in Health Studies run at Leeds Met.

Our main UK based Masters remains the MSc Public Health – Health Promotion, and the current course leader is James Woodall. In the past, the course has been led by Sylvia, myself, Mary Green, Ruth Cross and Ivy O’Neil. We have been fortunate to have had a number of external examiners attached to the course, all large figures within the epistemic health promotion community – Amanda Amos, David Stears, Jane Wills, Angela Scriven, and currently, Peter Duncan.

Our recent book (Dixey 2012) comes out of our experience of running the course, comprises an overview of all our ideas about health promotion and is designed to be applicable globally. It reasserts the radical intention of health promotion, seeing it as a social movement to bring about health justice. In the introduction, we say:

“What our book does aim to do is to set out some of the key principles and ideas, or in more academic terms, to explore the discourse surrounding health promotion in the twenty first century. It not only attempts to explore what health promotion is, but also to ask some uncomfortable questions about health promotion – in short, to be critical of it. Being critical, according to some, is what defines our age (Jencks, 2007) – being sceptical and asking questions…As such then, this book does aim to be a guide to ‘how to think about health promotion’.”

At the end of chapter one, we write:

“For now, distilling the key points from this discussion, we propose (in no particular order), that health promotion therefore should:

1.     Resist biomedical models of health and advocate for the broader social model of health to be adopted at policy making levels;

2.      Place empowerment and the redistribution of power at the centre, so as to bring transformation to individuals, communities, organizations and societies with the aim of produce greater health;

3.     Involve collaborative working and strong partnerships;

4.     Take a salutogenic approach and promote the importance of ‘good health’;

5.     Take an assets perspective (rather than a deficits one), with a stress on capability;

6.     Prioritize the most vulnerable and disadvantaged communities, thus tackling areas facing the worst inequities;

7.     Start with where people are, use ‘constructionist epistemologies’, respect and value local knowledge and lay epidemiologies;

8.     Use ethical change processes;

9.     Have capable, skilled health promotion workers working alongside communities as allies;

10.  Adopt anti-oppressive practices, challenge racism, sexism, disablism and any other practices and institutions which oppress people;

11.  Adopt ecological principles, sustainability and a concern for the environment;

12.  Invest in the capabilities of the health promotion workforce (both professional and lay), paying attention to life-long learning;

13.  Use evidence-based practice, ‘real world’ evaluation methods.

14.  Produce ‘big picture’ change at the societal level and also ‘small picture’ change, working with communities and individuals.”

Whether the book ‘works’ as a guide to health promotion in the 21st century and is applicable to all countries, no matter what state of ‘development’ remains to be seen. Please let us know!

(You can get in touch through the comment facility of this blog, or email us r.dixey@leedsemt.ac.uk)

We remain passionate about tackling health inequalities and we believe that we put our principles into practice, making sure that in our research we are inclusive, use participative methodologies, such as working with lay researchers; and in our teaching we are empowering another generation of health promotion workers. Our concern with marginalized communities can be seen in our work with, among other things, health promoting prisons and with waste collectors. We also have a major initiative called Health Together: Evidence, Policy and practice for Community Engagement. (leedsmet.ac.uk/healthtogether). 

This round up of health promotion at Leeds Met is inevitably personal and partial, so I’m sorry if I’ve missed anything out. It’s been a fabulous journey for me and I’m proud to have been a part of health promotion at this University. I stepped down from managing the team in 2011 so that I could concentrate more on writing and other projects and also on the professorship that I was given in 2008. (My inaugural lecture is on youtube, as will be Jane South’s later in 2013). There are not many professors in health promotion, but we have two – myself and Jane South. I think it’s fair to say too, that we are one of the largest specialist academic health promotion departments anywhere. The research centre has become a part of the Institute of Health and Wellbeing, enabling us to gain synergies from a wider research community through collaborating with other Centres in the University. Just recently I have been given a part time role in the University as Director of Postgraduate Students which means I have a responsibility for the 650 PhD students across the University. Playing this role I can see that there is all sorts of health promotion research and teaching going on other parts of the University – in the Carnegie Faculty for example, focusing on physical activity, lifestyle and weight management. And as the Arts, sustainable building, healthy cities, politics and social policy and so many other disciplines all have a bearing on health, we are at the centre of a huge amount of creativity as far as health promotion and wellbeing are concerned.

References:

Cattan, M. & Tilford, S. (2006) Mental Health Promotion: A lifespan approach, McGraw Hill International, Maidenhead

Delaney, F. (1994) Muddling through the middle ground: theoretical concerns in intersectoral collaboration and health promotion, Health Promotion International. 9(3), 217-225

Dixey, R, (2012) Health Promotion: Global Principles and Practice. Wallingford: CABI Press

Dixey, R. and Green, M. (2009) Sustainability of the Health Care Workforce in Africa: A Way Forward in Zambia, The International Journal of Environmental, Cultural, Economic and Social Sustainability, 5(5), 301-310

Dixey, R. and Njai, M. (2012) The Call to Action: Health Promotion in The Gambia - Closing the Implementation Gap? Global Health Promotion (in press)

Foster, S., Dixey, R., Oberlin, A. and Nkhama, E. (2012) ‘Sweeping is women's work’: employment and empowerment opportunities for women through engagement in solid waste management in Tanzania and Zambia. International Journal of Health Promotion and Education. 50 (4) July, pp.203-217.

French, J. & Milner, S. (1993) Should we accept the status quo?, Health Education Journal, 52(2), 98-101

Green, J. & South, J. (2006) Evaluation, Open University Press, Maindenhead

Green, J. & Tones, K. (2010) Health Promotion: Planning and Strategies 2^nd edition, Sage, London

Hubley, J. (1993) Health Communication: An action guide to health promotion and health education. MacMillan

Hubley, J., Copeman, J., and Woodall, J., (2012) Practical Health Promotion. Polity Press, Second edition.

South, J., White, J., and Gamsu, M. (2012) People Centred Public Health: Policy and Practice. Polity press.

Tones, K. (2001) Health promotion: the empowerment imperative, in Scriven, A. & Orme, J. (eds.) Health promotion: professional perspectives 2nd edition, Palgrave, London

Tones, K. & Tilford, S. (1991, 2001) Health Promotion, effectiveness, efficiency and equity, Nelson Thornes, Cheltenham

Tones, K. & Green, J. (2004)  Health promotion: Planning and Strategies, Sage, London

Warwick- Booth, L., Cross, R. and Lowcock, D. (2012) Health Studies: An Overview Of Contemporary Perspectives, Polity Press,  Cambridge

Warwick-Booth, L., Cross, R., & Lowcock, D. (forthcoming) Health Studies: A Contemporary Overview, Polity Press, Cambridge

Woodall, J., Raine, G., South, J. & Warwick-Booth, L. (2010) Empowerment & health and well-being: evidence review, Leeds, Centre for Health Promotion Research, Leeds Metropolitan University

Women, leadership and peace

I often wonder what the world would look like if women were in power. Maybe you do too.

By power, I mean in formal positions of power, prominent in public life – if there were, for example, 502 women and 145 men in the UK Parliament. (There are 502 men and 145 women by the way…) Would childcare be so expensive? Would, across the water in Ireland, women die for lack of abortion (as happened recently)? How would priorities be different?

A recently published report, From the Ground Up, produced by the Institute of Development Studies and funded by ActionAid and Womankind Worldwide, shows how perspectives on peace are different from women’s point of view. Peace, as I’ve said before in this blog, is the first prerequisite for health. The Ottawa Charter points out this fact -  it should be obvious, but it isn’t always given its due.

The From the Ground Up report suggests that women define peace more broadly than men, and did not consider that their lives were peaceful, even if there was no civil conflict occurring, because their lives were not free from violence, harassment and abuse. Men viewed peace as the opposite of formal conflict, and the gender difference is summed up by an Afghani woman: “we’re not talking about big war, but peace for us also means no domestic violence”.  Afghanistan was one of the countries surveyed, along with Sierra Leone, Liberia, Nepal, and Pakistan. It’s well known that conflict and lack of peace affects men and women differently but what the report also points out is how women are largely absent from high level negotiations at national or international level, despite a UN security council resolution in 2000 which called for more equal participation of women in maintaining and promoting sustainable peace worldwide. In 17 out of 24 recent major peace treaties, there were no women involved in signing agreements; there have been no female chief mediators in UN-mediated peace talks. Women are renowned peacemakers in homes and communities, and some feminists would argue that if there were more women heads of state, there would be fewer wars.  Women as a peace-keeping resource is thus being under-used, but also the prominence of men in peace negotiations means that women’s and girls’ needs are not emphasized.

Women have been prominent in local peace movements, from Asha Amin and Starlin Abdi Arush in Somalia, Ana Guadalupe Martinez in El Salvador, Luz Mendez in Guatemala, Martha Karua in Kenya, plus all the women in the Northern Ireland peace coalitions such as Monica McWilliams. It was marvelous to see Fatou Bensouda appointed as the chief prosecutor of the international criminal court but this prominence at the top of a key international agency is rare. Women are more likely to be involved in peace making at the informal stages, forming local coalitions and peace groups, or brokering peace in their neighbourhoods and communities. These grassroots activities receive no funding very often, and women’s skills as bridge-builders, conflict resolvers, in dialogue and building trust, is often devalued.

The report From the Ground Up recommends that 30% of those involved in all local, national and international peace negotiation processes are women.  It also calls for 15% of peace building aid to be directed at aid to address women’s needs.  Some of the report’s findings however, also echo some of the UN and WHO’s declarations about peace, that it is not merely the absence of war, (just as health is not merely the absence of disease) – peace must also mean an absence of the structural violence caused by the unequal distribution of wealth, resources and other ‘goods’ within societies. This structural violence is often reified into patterns of discrimination, such as under apartheid in the ‘old’ South Africa, or into systematic oppression on the basis of gender, sexual orientation, age and so on.

It has been claimed that investing in health is investing in peace. See http://www.who.int/hac/techguidance/hbp/Conflict.pdf

Many of these high-blown and well-intentioned statements emanating from summits can be found in UN and WHO documents. Implementing their content so as to enable people to live in greater peace is another matter, and doesn’t appear to be happening. As the From the Ground Up report suggests, unless women are represented at all levels of decisions making, peace is less likely.

Navi Pillay, UN commissioner for human rights is one prominent woman calling attention to global conflict. Recently she has written about the upsurge of violence in the Democratic Republic of Congo. Last week, Goma fell again into the hands of armed men, the M23 movement. One of its leaders is Bosco Ntanganda, who has been indicted by the international criminal court for the mass killings in 2008 in the DRC. Navi Pillay was one of those compiling a report documenting 617 violent incidents in the DCR from 1993 to 2003, all of them involving gross violations of basic human rights. The Congolese army, let alone the rebel groups have perpetrated acts including extreme sexual violence, mass rapes, violent dismantling of refugee camps, using forced child soldiers, and murder of civilians. The UN expert panel report published last week shows that the rebel groups have received assistance form neighbouring countries, such as Rwanda. I often use Rwanda as an example of a country where more than half of the MPs are women – 52% - yet in this specific case, they do not appear to be helping to bring peace to their larger neighbour. These neighbouring countries are essential to brokering peace.

I have just returned from contributing to a symposium on empowerment and health promotion in Germany, as along with Glenn Laverack and Mark Dooris and a few other invited speakers, we were helping German colleagues to establish the idea of empowerment in German public health discourse. I went along to a mass in Regensburg cathedral on Sunday to hear the famous boys’ choir. Speaking as an atheist, I was struck by the display of white male privilege, all the priests and officiates men, and the opulence in this wealthiest of European countries was very clear. I have no idea how it all relates to the message of Christ in the new testament (and I do know my new testament) but no matter. What was clear was that women did not have a place here except in the congregation and of course this is in the same week that the Anglican Church in England has decided not to allow women to become bishops. I know that male leaders of the church – many bishops – were devastated, and that women in the laity were amongst those leading the no vote. It does seem extraordinary and a missed opportunity for women to play leadership roles in the church, to make it more relevant to the 21^st century, and to have a voice in peace-making. If the church cannot do this, what is it for? The tiny African country of Swaziland already has a woman bishop, and if the vote had gone through in England, Rose Hudson-Wilkin, a woman of black African descent might have become the first bishop. Wouldn’t that have been great? I am at a loss to understand why anyone would not think that women have a role to play at the highest levels.

Shakespeare wrote 788 parts for men and 141 for women. I’m not changing the subject here – I’m still talking about women as peacemakers. Phyllida Lloyd, the successful feminist film and theatre director is currently directing a production of Shakespeare’s Julius Caesar, a play all about male power, conflict and war. This production is different as it’s all female cast. A play about fallen dictators, regime change, war and peace clearly has modern relevance. Harriet Walters will play Brutus, and as she says, “There is something in… the ‘alienating’ effect of seeing women paly these parts. The play is essentially about the power vacuum after a dictator falls, and how you tend to fill it using the template of what has gone before. And there’s something about an all-women cast doing that”. Showing women making war points out how odd it is for them to do so – and conversely, how ‘normal’ it is for (some) men to do so.

Austerity Kills

Bradley Wiggins’ high profile accident has brought attention to cycle safety and the government has used it to publicise the £30 million it has set aside for improvements to road junctions with cyclists in mind. We now that the danger of cycling is the major factor putting more people off using this as a healthier way to get around, or for leisure. In fact, the £30 million is about the same amount that the Mayor of London, Boris Johnson, has cut from the capital’s road safety budget and also amounts to £64,000 per council in the UK – not enough to improve even one dangerous junction.  Last year London alone had a 23% increase in cycling casualties and there was also an increase in pedestrian casualties after a decade of seeing reduced numbers.  In the cycling mecca of Holland, the government spends £25 per person per year on cycling infrastructure. Our government spends £1.  The impetus created by the Olympics and the success of the cycling team did start to get more people on their bikes. Now though it looks as if people will weigh up the odds and decide that the risks are too great, so any putative health benefits will go. And it looks as though dedicated cyclists will be at greater risk of death or injury in the future.

These kinds of cuts are happening in many sectors of public life. However, the austerity measures being endured by the population of the UK are being disproportionately administered across the country – to the extent that Hilary Benn, the shadow secretary for local government has said the cuts are “politically motivated”. He has stated that of the 50 worst hit councils, 43 are Labour and of the 50 least hit, 42 are Tory. The 50 councils least affected are seeing cuts of £16 per head, many of them in more affluent parts of the south of England. The 50 worst affected are seeing cuts of £160 per head and are predominantly northern, in Liverpool, Rochdale, South Tyneside, or in inner London such as Hackney.  Haringey in London, often cited as a deprived local authority (and is indeed the 11^th most deprived in Britain) has £84 million of budget cuts, amounting to £170 per head.

Some of the things happening at the moment are not likely to be captured by the conventional methods of measures of deprivation. The Carstairs deprivation scores for example, which are based on adult unemployment, car ownership, social class composition and overcrowding, show how one area can differ from another in terms of relative deprivation, but does not take into account aspects of personal behaviour such as drug use, smoking or poor diet. It’s acknowledged the Carstairs measure no longer captures relative deprivation as effectively in the 21^st century compared to the 1980s.

Whilst academics are clearly extremely concerned about the effects of austerity and poverty on health, there will be a time lag before data are collected to demonstrate the effect and also before robust measures are developed to measure the effect. In the meantime, some journalists are doing an excellent job in showing the impact of austerity. Amelia Hill for example, in this weeks’ Guardian newspaper (19/11/12) shows the pernicious rise of food poverty. She reports research from the Joseph Rowntree Trust which shows that food price have risen by 32% since 2007, twice the EU average. FareShare, a charity which feeds 36,500 people every day is seeing people coming for help who are living on “what were once regarded as reasonable salaries” but who “can no longer afford to eat enough”.  A Save the Children report shows that of 5,000 families in the UK earning £30,000 a year, two thirds had to go into debt, avoid paying bills, not replace worn out clothing and for the parents to skip meals, in order for the children to have enough to eat. A survey of teachers shows that four out of five teachers see children who are hungry in the morning.

The government’s own statistics show that eating healthily has become more expensive, with the price of vegetables rising by 22% since 2007 and fruit by 34%. Between 2007 and 2010, low-income households cut the amount of food they buy by 11%. If you believe, as many health promoters do, and as I certainly do, that the food we eat – the stuff we put into our bodies – is one of the very most important determinants of health, then these effects of austerity are potentially the most worrying. Already the UK has the highest rates of obesity after the USA and rates of liver diseases associated with it are suddenly in the media. The lack of micronutrients and other essentials in the diet are likely to affect immunity and store up health problems. What’s as depressing to me is that those on poverty incomes and poverty diets no longer enjoy food. Food is one of the great joys of life – there’s a celebration of good food in the UK and we seem to have caught up with some of our continental neighbours in enjoying good food, grown and cooked carefully. Amelia Hill’s article though, sadly ends with one of those she interviewed saying, of the food he’d been forced to buy due to his low income, “it all looks so cheap and nasty. To be honest, just looking at it takes my appetite away”.

Austerity not only kills, it also kills quality of life and takes away any joy.

Empowerment and President Obama

We were teaching about empowerment today on our Masters course in Public Health – Health Promotion here at Leeds Met. My colleague Dr. James Woodall was, as part of the session, asking students to critique a paper he and two other colleagues had written. The paper questions whether ‘empowerment’ has lost its radical roots and is now used too casually and without precise definition. (Woodall et al 2011)

Power is a key concept that we dissect when we discuss empowerment, and this inevitably leads to a discussion of powerlessness. Powerlessness, according to Solomon (1976) comes from three potential sources: firstly there are systems which systematically deny powerless groups opportunities to take action; secondly there are the negative images which oppressed people have of themselves, a form of self-oppression, and thirdly there are the negative experiences which oppressed people undergo in their everyday interactions with systems, institutions or the media.

In this week where Barack Obama has been re-elected (Hurrah!) it’s interesting to think about the effect of such an election on power structures and empowerment. When he was elected first time around, black people all over the world were delighted – what a message – to see a black man as the President of the world’s most powerful country, meaning that for the first time, a black man was the most powerful person in the world. (That depends, of course, on how much power you think a President can have, given the forces of capitalism and conservatism in the USA). In terms of the second of Solomon’s sources of powerlessness, Obama’s victories have had a huge impact on positive images and thus on dismantling self-oppression.

Marginalized people – and health promotion is principally concerned with those who are marginalized – have been able to use the election system to their advantage. This doesn’t happen often. In the election that took place this week, for once, the white, male majority did not get their candidate of choice. Exit polls show that 45% of men and 55% of women voted for Obama; of white men, 35% voted for him and 42% of white women. 87% of black men and 96% of black women and 65% of Latino men and 76% of Latino women voted for Obama. In terms of ‘race’ alone, 39% of white voters voted for Obama, 93% of African Americans, 71% of Latinos and 73% of Asians. Those earning less than $50,000 were more likely to vote for Obama – 60% as opposed to 44% of those earning over $100,000.

So all in all, poorer, female, black, Hispanic and Asian people were able to make their vote count and to elect someone who they felt would represent their interests. This is essential if one of the key outcomes of empowerment – systems change – is to happen. It also resonates with the first of Solomon’s points about sources of powerlessness, that systems operate to exclude certain groups in a systematic way. There is a good chance, with a second term, that Obama will be able to bring about permanent systems change. The implementation of the reform of health services must be a major plank of this systems change. One thing which seemed to make a difference this time around was persuading those who don’t normally vote, to get out and make sure they did.  They stopped Mitt Romney doing what he had pledged to do in cutting after school programmes, job training programmes, Head Start, Planned Parenthood and other social projects which primarily target the marginalized. Now, we have a President who has pledged to invest in education, tackle climate change, reform immigration policy; this means for example, that the eleven million undocumented immigrants might be able to gain a path to citizenship. I don’t agree with all aspects of America’s foreign policy but I’m certain it will be a lot more enlightened than it would have been if a Republican had got into the White House.

No doubt Obama will not be able to be as radical as he’d like, given the opposition of Republicans, but in terms of empowerment, it’s a great stride forward.

The change of leadership in China, also happening this week, gives hope that the two most influential countries in the world could take us into a different era of politics.

References:

Solomon, B.B. (1976) Black Empowerment: Social Work in Oppressed Communities, Columbia University Press, New York

Woodall, J., Warwick-Booth, L., Cross. R. (2012) Has empowerment lost its power? Health Education Research. 27 (4), 742-745.