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International year of the family report (phase 1): an overview of academic attempts to define the family

Contents:

Summary 1. What is the family? 2. Health care professionals views of the family 3. The Changing Family 4. The role of the family in creating and maintaining health 5. The theoretical distinction between health education and health promotion and its relationship to the family 6. A review of health promotion / education policies and intiatives oriented towards the family 7. Recommendations for stage two of HEBS International Year of the Family Project 8. References Appendix: Inventory of health education and health promotion materials and initiatives

6. A review of health promotion / education policies and intiatives oriented towards the family

6.1 Introduction

A considerable amount of time was directed towards the collection and review of health education and/or promotion initiatives and policy statements. I targeted, in the first instance, policy statements that issued from various tiers of the formal health structure in Scotland, and also the policy documents produced by bodies contributing to the development of policy in this area. The Scottish Office, Health Boards, Health Councils and major voluntary sector organisations, amongst others, were approached. The inventory at the end of this document provides a more comprehensive list of the organisations contacted, as well as details of the documents reviewed.

Due to the volume of policy documents and information about specific initiatives received it is necessary to impose a structure on this review. Accordingly, central policy documents are reviewed under headings reflecting their point of issue. However, in the case of some voluntary sector initiatives the ‘issue area’ forms the heading. A section is also included on ‘Joint Working’ initiatives. At the outset it must be noted that the aim here is not to recount the content of all the policy documents and initiatives, but rather to give a flavour of what is happening in Scotland with regard to family health education and/or health promotion. Therefore, in the case of Health Boards only four regions policies are reviewed; these are chosen to illustrate the variation in current approaches. A bullet point summary is provided at the end to this section.

6.2 The Scottish Office

None of the Scottish Office policy statements relating to health education and/or health promotion refer explicitly to the family. Its publications over the last few years have set national targets for health improvements which are predominantly oriented around the individual opting for what are variously termed ‘lifestyle changes’ or moving to a ‘positive lifestyle’.Scotland’s Health: a challenge to us all sees such changes as being achievable through ‘individual decisions’ supported by government groups and ‘communities’. The family, as a diverse social group to which most people belong, is not mentioned. The emphasis remains upon individual responsibility.

Targets and initiatives are important but ultimately the improvements in health we all seek will only be brought about by the determination of each one of us to give effect to necessary changes in our lifestyles and habits. The forms of personal behaviour which most contribute to ill-health are smoking, poor diet, excessive use of alcohol and lack of physical exercise (Scotland’s Health: a challenge to us all, p12).

Similarly, the leaflet Scotland’s health: a challenge to you, is designed for the individual to read with a view to making a ‘lifestyle change’. It lists guide-lines for ‘sensible living’ which refer to the family implicitly in ‘Tips for the Home’ and the sphere of accident prevention. However, most of its contents flow from the assertion that ‘personal behaviours contribute to ill health’, though other contributory factors external to individual behaviour, such as ‘housing, unemployment and socio-economic circumstances in general’ are mentioned very briefly (in one sentence).

The 1993 Report The Scottish Diet considers the main obstacles to dietary change as ‘motivational’, and whilst it never refers directly to the family, it does identify the ‘household management of food provision’ as the forum in which diets can be improved, ‘especially amongst low income groups’ (p76).

Health Education in Scotland (1991) stresses the importance of collaboration between Health Boards and Social Work Departments in areas of ‘multiple deprivation’, and espouses what it terms a ‘broader health perspective’ based on a ‘recognition’ that health promotion involves issues of the environment, housing, and urban renewal, amongst other things.

The statement also recognises that ‘Health Education will also have to adapt to changing family structures’, and includes amongst its objectives the elevation of public awareness of the ‘problem of accidents in the home’ (particularly amongst the young and the elderly), and the desirability of drawing parents, as well as young people, professionals and volunteers, into ‘drug education’ programmes. Much of the success of such aims it sees as dependent upon the involvement of communities in the development and implementation of health education programmes which, the document emphasises, ‘can have a powerful influence on their success through the sense of ownership this brings’ (p18).

The report notes that Social Work departments are often engaged in programmes with families in socio-economic groups where ‘illness and unhealthy lifestyles are often a particular feature’ (p19). There are opportunities, it concludes, for health care professionals, working in co-operation with social workers, to ‘promote good health in providing for families with young children’ (p19). As will be shown below, Fife is one region that has produced a strategic document in which health promotion is discussed in the context of the changes in Community Care.

6.3 Health Boards

Within Health Boards’ literatures and activities there is a tendency to categorise activities as either topic-based or settings-based (for example, see Greater Glasgow Health Board). Hence, campaigns against smoking, drug abuse, bad diets and the promotion of safe sex can be seen as topic-based programmes, whilst safety at work or community development initiatives are programmes that are settings-based. Inevitably there is a great deal of overlap between these two broad classifications and topic-based issues need to be operationalised within specific settings. Similarly settings-based initiatives normally address a range of specific topics. Interestingly, however, the family is never cited as being a forum for settings-based initiatives, except insofar as the ‘household’ is a context of accident prevention policy. Rather, when the family is mentioned it is normally in relation to topic-based projects, such as the role parenting can play in early health ‘education’ (see below). This may well reflect Health Boards’ recognition of: the wide variety of family structures; the fact that families live in different geographical settings; and that the needs of individual family members differ according to their age and sex.

One curiosity is that the ‘workplace’ is frequently discussed in terms of a health setting, but recognition that the family, or at least the household, might also be a place of work is not forthcoming. For instance, the Operational Plan of Greater Glasgow’s Department of Health Promotion aims to ‘cultivate the workplace as a setting for health promotion, through developing health policies and providing opportunities for lifestyle changes in the key worksites’. In conducting this part of the research, no evidence of policy-makers giving consideration to the work done, mainly by women, in the household, was evidenced.

The original brief for this report requested information on whether family health promotion/education initiatives utilised a broad view of health (including emotional, social and environmental elements) or whether they were working with a narrower ‘physical illness’ model. The answer to this question is complex. Most literature produced by Health Boards espouses broad definitions of health, often citing the World Health Organisation (WHO) when setting out aims and objectives (see, for example, the Annual Report of the Director of Public Health in Lothian, 1992). Health Boards tend to readily acknowledge the relationship between socio-economic and geographical situations and their population’s health.

Health Boards also often stand between the low level, bottom-up, community development initiatives and the top-down health education-oriented policies found in Scottish Office materials. It would be wrong, however, to give the impression that all of the Health Boards are following broadly similar policies with regard to health education and health promotion. Although all Health Boards are producing local health targets as required by the Scottish Office's Challenge to us all, their rhetoric and methods for achieving these vary considerably. The approaches of Glasgow and Lothian, for instance, are significantly different from those of Argyll and Clyde. The policies and initiatives of these three Regions are briefly reviewed below.

6.4 Lothian

The Annual Report of Lothian's Director of Public Health (1992) contains a section entitled Social Environment within the Family (pp 24-7) which notes the importance of emotional relationships and parenting and the problems (such as unemployment) facing families. It notes that because of the physical dangers to which children are increasingly vulnerable to when playing outdoors, ‘parents are keen to encourage children to follow indoor pursuits such as TV and video games’. This was the only example in the search of consideration being given to aspects of emotional health bound up with family relationships, which also considered how changing patterns in the leisure activities of families, particularly children, may be related to issues of health promotion. The subsequent section on ‘Poverty’ notes that ‘Low income also increases the chances of families having poor access to health care and to social and recreational facilities’ (p33), but that despite this ‘research shows that all parents...place a high priority on health and set high standards for the health of their children’. Finally it recommends that ‘each of us should do all we can to support and help others - in our families, in the neighbourhood, at work and in the wider community - particularly for children and families’ (p 138).

Health in Lothian: Annual Report (1992) , despite recognising the importance of life-style issues, places a strong emphasis upon a broad range of environmental influences on health (ranging from ecology, through unemployment, to the influence of television and the impact of poverty). The report draws upon the themes within Facts of life (a joint UNICEF, WHO, UNESCO AND UNFPA document) and in an appendix is found the World Declaration on the Survival, Protection and Development of Children. Within the document there is a clear wish, at least at the level of rhetoric, to place Lothian’s health issues and initiatives within a broad global context. Attention is drawn to international issues and solidarity is sought of, and requested from, other nations.

6.5 Greater Glasgow

Greater Glasgow’s Health Promotion Strategy begins by asking ‘who should be involved?’ (p3) and lists ‘health education, medicine, nursing, teaching, housing, social work and environmental health’. Subsequently, the report notes that:

The task for professionals is to enable individuals and communities to live healthy lives. Therefore to be successful, health promotion depends on community participation but to achieve this, comprehensive programmes of health promotion need to be established in key community settings (primary health care, hospitals, schools, and other educational institutions, the work-place, deprived communities etc.) and developed with key community groups (e.g. children, women, expectant parents/parents of babies and young children, ethnic minorities, etc.)

What is noticeably absent is any explicit mention of the family, apart from more oblique references to ‘agencies which influence health’. In fact, it is not until the list of various programmes in the appendix that families are discussed, and then it is in relation to a programme aimed at the Promotion of Child Health and Safety (p 15). Here three of the central objectives are noted as being:

• To equip parents to be family health promoters
• To prevent accidents in the home by promoting home safety
• To pilot the use of a parent-held record as a tool for health promotion

6.6 Argyll and Clyde

Argyll and Clyde’s Health Promotion Strategy (1993) whilst quoting the WHO’s definition of health on its cover, focuses almost totally upon the life-style factors which affect health. The document sticks closely to the national targets set by the Scottish Office and notes that, in line with the strategy advocated by HEBS, four settings will be targeted: Health Service, Schools, Workplace and Community and Voluntary Groups.

Noticeable by its absence is any reference to the family as a setting. Within the region a ‘life-style’ survey has been conducted and this is used to guide initiatives and programmes to help promote health. Socio-economic issues such as the effects of poverty upon health in both its physical and emotional/psychological dimensions, are not explicitly addressed. The emphasis within the Argyll and Clyde’s Health Promotion Strategy (1993) is captured well in the following quotation relating to work-place initiatives:

A senior Health Promotion Officer has been appointed to assist workplaces to develop ‘health promoting premises’. This will include policies on topics such as smoking, nutrition, stress and alcohol aimed at providing a working environment which supports people making healthy choices, offering support mechanisms to staff to help them make changes and supplying information to increase awareness (Argyll and Clyde’s Health Promotion Strategy 1993 p 18).

6.7 Joint working

A further important and recurrent theme during conversations with workers within the health education/promotion field (at all levels) was their frustration at the perceived lack of co-ordination between various agencies (statutory, voluntary ‘not-for-profit’, commercial and informal). Many people working in health education/promotion appear to believe that for objectives to be realised, it is necessary for all sectors to work together. The need for co-operation between various sectors is something explicitly recognised in recent Scottish Office literature (e.g. Health in Scotland 1991). Most of the workers who I have spoken to do not think that this is happening at present. The notable exceptions to this being Fife’s policy document ‘Towards 2000’ which is a joint strategic document between the Health Board and Regional Council: and the work in Glasgow through the Healthy Cities and the Glasgow 2000 initiatives.

6.8 Fife

Fife’s Towards 2000 is a good example of how health promotion and community care policy has been linked. It takes the view that ‘social and health needs are so enmeshed amongst client groups (e.g. children and families) that joint planning and joint operational activity are essential’. To this end, a ‘multidisciplinary’ approach to the provision of services to client groups has been adopted, where the Social Work Department and the health Board co-operate with Housing and Education Departments and the independent sector. Amongst its goals, notably, is a commitment to ‘create a healthy environment at home (my emphasis), work, and leisure’.

Fife has also adopted the recommendations made in Health Care and Travelling People: A Charter for Health for Travelling People, produced by the Scottish Association of Health Councils in September 1992. This report arose from, amongst other things, a concern over the extent to which Health Needs Assessments take account of travelling families. Since 1988, the community care unit of Fife Health board has allocated 50 per cent of one Health Visitor’s time specifically to Travelling People in the Health Board’s area. The Board has issued Parent Held Child Health Care Records and has developed a Traveller Held Health Care Record.

Another important jointly produced document is the Lothian Children’s Family Charter (1991). This document was developed jointly between the Social Work Department, the Education Department and the Health Board and, in its statement of principles, affirms ‘the central importance of the child and the primacy of the family and accepts the obligation to listen directly and carefully to their wishes and feelings affecting the quality of life’. It notes that it is ‘firmly committed to putting the family at the centre of (its) endeavours’ (p3). Under the section relating to Health: safety and security thirteen principles are laid down. Four of these principles are noted to be entitlements under the terms of the charter.

1) Opportunities for their parents to seek advice and comment on their health and educational development. This advice should be shared in ways appropriate to understanding, sensitivities, background and culture of the individuals involved.

2) A school curriculum which should help children to protect themselves, e.g. against bullying or physical/emotional/sexual abuse: awareness of the importance of environmental conservation.

8) Help to overcome the effects of any harm which has already been experienced.

13) Transitions of health care from hospital to home, and between other forms of care, e.g. home to school or from school to school, being discussed and agreed by themselves and parent(s).

Health Education, according to the Charter, ‘should be provided in schools and by parents at home’, and ought to include issues such as nutrition and diet, decisions about smoking, advice about responsible relationships, family planning, sex education and the risks of HIV and AIDS. Overall, then, there is a concern that wherever possible, ‘parents and children should be involved in decisions about their health’.

6.9 Community level

The top-down medically oriented and bottom-up community development approaches have been discussed in a previous section of this report. This section will concentrate on the WHO’s Healthy Cities Projects and how they relate to families. The Drumchapel Community Health Project, as one example, works on a very much ‘bottom-up’ community development model. Thus the vehicle of producing a community health profile was utilised in order to enable local people to identify their own health needs and to facilitate collaboration between statutory agencies and the local community. The key principles behind the initiative are stated as being ‘empowerment, participation and collaboration’ (ibid. p 32).

One crucial way of empowering local people is to give them access, on an equal basis, to professionals representing different local agencies. To be on first names terms with these people and feel able to get in touch with them with a query or request. ... But it is not only barriers between workers and residents that were broken down; involving representatives from Housing, Social Work and the Local Volunteer Project in defining the local health agenda, had a very powerful effect on these agencies’ attitudes to local health issues (Kennedy 1992 pp 32-33)

What the Glasgow Healthy City Project terms the ‘whole person approach’ takes account of all the inter-related social and economic factors which affect health yet, perhaps surprisingly, family formation and family structures are not mentioned in the discussion about individuals identifying their own health needs.

Within Lothian the ‘Health Hut’ in Greater Pilton runs a ‘Good Food Project’ which operates through ‘fruit and vegetables’ co-operatives in the area.

traditionally, health education messages have tended to urge people to eat good, healthy food without taking account of how expensive and often difficult this can be for people on low incomes of income support...against this background, a planning group was recently established to review the ways in which this service could develop on a more secure footing...The group looked at a variety of ways in which food could be provided more cheaply in the area and practical ways of encouraging more discussion about healthy food.

The Pilton initiatives stands as a good example of the ways in which a local community might attempt to improve local health, yet the family or the household are not cited as sites where people collectively eat, or where information is exchanged. Rather, the concentration is on attracting local people to become directly involved through engaging the interest of community groups, such as women’s groups.

6.10 Accident Prevention

Although most policy documents reviewed above discuss the importance of accident prevention, and the role parenting plays in this process, it is worth considering the Child Accident Prevention Trust’s Basic Principle of Child Accident Prevention - A Guide to Action for its more detailed consideration of the factors at play in this sphere of health. In discussing the location of responsibility for accident prevention, this document is keen to point out that parents and children can play a role by ensuring a safe environment and safe products. However, it also notes the links between social class and deaths caused by accidents - ‘Children from economically deprived backgrounds have a markedly higher death rate from accidents’ (p16). It is keen to stress the advantages of local action which ‘lie in the possibility of affecting policies and priorities by raising public awareness, educating parents and children, heightening the individual’s and community’s sense of responsibility to care for and protect children’. Furthermore, it concludes that ‘District health authorities and local councils are the starting point for action’ (p19).

The Trust suggests that this is most likely to happen through the contact between health service personnel (health visitors, district medical officers, GPs, practice staff, midwives, nurses, accident and emergency staff, paediatricians, community physicians, health promotion workers etc.) and parents and/or children, either in their general health promotion work or by influencing local policies. Parents, carers, childminders and children themselves are on the list of ‘who to target’, along with the health service personnel mentioned, the media, industry and commerce and education, but in terms of the ‘home’, most emphasis is placed on the ‘design and construction of the environment’ rather than education within its confines.

Summary of central findings

• Few policy initiatives are aimed explicitly at the family.
• However, most health education and health promotion policies have implications for people living in families.
• Most policy statements which are directed towards families concentrate on ‘parenting’ and its importance in the field of accident prevention and child development.