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Health Promotion: Philosophy, Prejudice and Practice

"In the rush to make the world a better place many health promoters have forgotten how to think." This is the underlying premise of a compelling book by David Seedhouse, a New Zealand-based philosopher who challenges the key values and assumptions guiding health promotion practice.

Seedhouse maintains that health promotion is essentially prejudiced: every initiative conducted in the name of health promotion is ultimately based on human values rather than defensible, evidence-based

theory. To prove his contention, Seedhouse takes sharp aim at some of the ill-defined definitions and muddled models that form the (so-called) theoretical basis of health promotion.

Given the subject matter, Seedhouse could have easily produced yet another dry, deconstructivist critique of health promotion. The fact that the book is highly readable and entertaining is a testament to the author's writing skills. The accessability and educational value of the book is enhanced by the addition of a simulated dialogue centred on Diane, a young journalist assigned to write a feature on health promotion for her community newspaper.

To gather research for her article, Diane arranges a visit to the local public health unit, where she engages community health promoters in a discussion about appropriate responses to high risk drinking. As someone who has struggled to explain the parameters of health promotion to the uninitiated, the ensuing dialogue strikes an all too familiar chord:

Diane: Can we take stock for a minute? If I really were a client of yours I think I'd be seriously confused by now.

John: You'd be on your way back to the bar wouldn't you?

Diane: I might, you know. Look, when you said you are all part of a health promotion movement I assumed -- obviously naively -- that you'd all be pulling in the same direction. But that doesn't seem to be so. Martin's telling me to get a grip on my habit before it's too late, Ann wants to expand my self awareness so I can really and truly know whether I want to go on drinking and you, Carol, would close down the brewing industry if you could. Now does anyone want to tell me how I can make sense of this?

James: I know it looks confusing but it's not actually so bad... it's just that we disagree about the methods we use... but we're all for your health.

Diane: (Sceptical) So which method do you follow, James?

James: Well let's just say I mix and match.

Diane: But how do you do that? How do you decide when do go with Martin's model and when to be persuaded by Ann?

James: I'm Head of Department here, Diane. I try to be diplomatic.

As a remedy to what he views as the absence of sound ethical and theoretical principles guiding health promotion practice, Seedhouse proposes a foundations theory of health promotion. Health promoters utilizing the foundations theory, which equates health status with "the extent to which a person can function successfully," work to ensure that individuals and communities possess the requisite "foundations" for health. Broadly defined, these foundations include: basic needs (e.g., food, shelter, meaningful employment), access to health-related information, skill and confidence to act on information, connections with the external world, and (when needed) additional supports to cope with health problems or stressful life events.

Given this holistic viewpoint, the foundations theory appears to imply that any initiative aimed at enabling people to live better lives is legitimate health promotion practice. Seedhouse dispels this notion by setting practical and ethical limits on the role of health promotion

practitioners. According to Seedhouse, the role of any health promotion practitioner working with an individual or small group is to "recognize the importance of the foundations for that individual or group in context -- to identify with or for each individual or group those foundational components which are lacking, or those which are most in need of renovation -- and then to work on those aspects of the problem so defined, in a way most appropriate to the skills of the health worker" (1997, p. 138-39). To assist practitioners in this process, Seedhouse supplements his theory with a series of helpful questions, case studies and exercises.

As a critic of the shallow assumptions underlying many health promotion initiatives, Seedhouse doesn't pull any punches. Assertions like the following seem calculated to put health promoters on the defensive:

"If you think that smoking is always a problem and is therefore necessarily a central concern for health promotion, then you are letting your prejudice run away with you" (1997, p. 180).

Conversely, the defensive health promoter can point to the shortcomings of Seedhouse's work: the patronizing tone of the book; his apparent assumption that no one in the field of health promotion has given any serious consideration to the theoretical and conceptual limitations he raises (a number of health promotion theorists who have done so are conspicuously absent from his reference list); his nihilistic contention that health promotion, in all its guises, is based on prejudice when, in fact, a wide range of health promotion strategies are grounded firmly in theory and evidence.

Yet by the end of the book, I was left with the uncomfortable feeling that Seedhouse's criticisms, while unduly harsh and overstated, are not without foundation. All too often, health promotion addresses complex health issues with reactive responses formed in the absence of clear theoretical and ethical assumptions. If nothing else, Seedhouse challenges health promoters to be clear about the theories, values and principles underlying their work. Given that the prevailing lack of clarity is one of the key barriers to the evolution of health promotion into a mature discipline, a careful reading of this book is a must for health promotion students and practitioners.

- submitted by Brian Hyndman, The Health Communication Unit,

Centre for Health Promotion, University of Toronto,